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r.= ■■ lUhesler, Ne« fork U6C9 uSA 

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= 16) 288 - i9S9 - Fa> 




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^(XoujUs^ 







HANDBOOK OF 



DISEASES OF THE EAR 



HANDBOOK Oi" 
DISEASES OF THE EAR 

FOR IHK L^i: ()1 ^ITDl.N'l^ AM) 
PRACirnONKRS 



BY 



KlCHAKl) LAKl-., E.R.CS. I.nu. 

, : .K >N. -iKXMKN-- llo-.lir.Vl. AND lOVAL 1; \l; II ■>l'l i Al. 



Willi I < 11 K ( ' II Ol KI I) l'l,\ri:s AMI 

:; okii.iN \i ii.i.r>iK\iu>N> 



i-orKTii I'.nnioN 

i<i;\l>i:|i AM) l.NLAIvGMD 



'I'l )l\i )N I' ) 
1). T. McAlNSH cV CO. 



5 ^J 3 i» 4 



INTRODUCTORY NOTE TO FIRST 
EDITION 

The writer takes this opportunity of expressing 
his indebtedness to Dr. C. Herbert Hall tor his 
kindness in revising the manuscript, and also his 
appn;ciation of the trouble involved. 



London, 

OctobiV, 1903. 



THIRD AND FOURTH EDITIONS 

'.A- "IKMl'CiKA Ml TAN I Ik 1.1 N(>> MUTAMUK IN ILLlb.' 

I-'ii^'s. 2i) 31. j;, arc from drawings su])plii-d 
by Mr. Harold Mole. I'.K.C.S., of Bristol, who 
also nviscfl nmcli ot tlu' manuscript for tne 
latter rdition. 

London. 



vii 



:lu. 



d >L 



\ 



.^ •«-<^^ 



«-\ •^-'-^l 



^/ 



CONTENTS 



CHAI'IER 

1. A HRIEF DESCKII'IKJ-N OF THL ANAlOMY OF THi: F-AK 

II. THK GENERAL EXAMINATION OF THE PATIENT THI , FECIAL 

EXAMINATION OF THL I'ATIENT - - ■ - 

III. SPF.CIAL SYMPTOMS AND THEIR IMPORT — INUICAIIONS FOR 

INTRANASAL TREATMENT . . - - 

IV. ESTIMATION OF THE ACUTENF-SS OF HIAKING 

V. GENERAL THERAPEFTICS— niE USE OF INSTRUMENTS 

VI. THE EXTEKNAI. EAR MALFORMATIONS, INJURIES, AND 

DISEASES— EXTERNAL ME ATUS— UISl: ASES OF THi:CERU- 
MINOUS (-.LANDS NEW I., KOWTllS— FOREIGN IiODIi:S IN 

iiii; i;xri:KNAL miatus— m ptuke of vnv. mi;mbkana 

TYMl'ANI ------ 

VII. EUSTACHIAN T I bE OBSTRUCTION - - - - 
VIII. ACUTE DISEASES OF THi: MIUKLI. 1;AR 

IX. CHRONIC NON-SUPPURATlVl; DIblOASI.S OF IHF .MIDDLE 

EAR FIXATION OF THl; MALLEUS 

X. CHRONIC SUPPURATIVE DISIIASF.S OF IHl; MIDDLE FAR 

XI, INTRACR.XNIAL CO.MPLICA 1 IONS . . - - 

XIF OPERATIONS .-.--- 

XUI. MALIGNANT DlbEAal. OF IHE FAR . - - - 

XIV. OTOSCLEROSIS ....-- 

XV. DISEASES OF THE INIERNAI. lAR — I)E.VF-M t TISM 
X"l. LIFl; ASSUKANCi; - - - - ■ 

APPI NDIX ------- 

INDEX ...--- 



I 



37 

47 

^5 



79 
I lo 

>U 
',U 

I.S2 

lyo 
236 

-4.1 

207 

270 



IX 



LIST OF ILLUSTRATIONS 



1 1. 
I .'. 

I V 

' I 
13 



17 

18. 



Ri^ht ^Ia^rolil ----■" 

Innrr Wall r,l Tympaiuim (Riuht) - - - - 

\erliLal Suction :hroa-h Right Temporal Bone 
Preparation sliowin- Attic au'l Cavum Tynipani 
T-ni panic \<ms, and O-isicles at liirth 

The Dssicles (Right) Articulate 1 - - - " 

Dissection showing the Relations oi the Chorda l-ympani and 
the (1>sirlcs - - - ■ " ' 

Diagram ol tho Tviiipanio Membrane, showing various 
Normal and Artiticial Points - - - - 

Dissection showing the Periosteum of the F.ustachian Tube 

continuous with Membrana i'rouria of the Dniin - 
Tympanic Membrane and Anterior Half cf l-Aistachian Tube, 
showing the Periosteum of the Latter continuous with the 
Substance of the Former - - - " " 

Vertical Section through Right Temporal Bone 
Teuii: iitum Tvmpani removed, expojmg Malleus and Sus- 
pensory Ligament - - - - " 
Sect'on through Si lerosed Mastoid Process - 
Cellular Mastoid Process - ■ - " " 
Seai(m iVerticab iiassnv; through th- Cavum Tvmpani and 
Antrum, showing the two larger Ossicles ;u .itit - 

Dissection of Semicircular Canals, showing their Relative 
Positions - - - " " 

Section of Temporal Bone cut thrcnigh Internal Auditory 
Meatus --'--' 

.\ural Speculum --■""' 

riniduhum's Nasal Speculum - - " ' 

l>i,i-ranim,itic. Sketch of Posterior Nare-. Ri-;lu Side in 
Diagram 1- Xo-iual - - " " " 

Polit/er's A. oumeter ----■" 
, Lucae'- T:^.-:^- !-=rL tCA - - - - - 

xi 



I'Al.E 

4 
5 

h 
9 

y 



12 

I') 

17 

u 
52 



Xll 



LIST Ol- ILI.USTRATIOXS 



F|i,. 

23- 

24. 
25- 

2(). 

27- 
2.S. 
21). 
.V- 
.!'■ 

3-- 

33- 
3»- 
33- 
3''- 
37- 
3'V 
3>J- 
•I"- 

41 

4-- 

4 V 

•It 

45- 

47- 

4^ 
4'l 



5 J 
53 ■ 
.')4 



Pro£es-<()r Lucac'> l.^ite^t I'ork - - - - 

Aural I'orceps for clcnn>inu tin- I-^ar with Cutton- .vool Mops - 
Siei^lu's I'lU'uiiKitii Spfi uliini att;i' hi.i! to DiNtamhu's Kare- 

fatteur 
Lucai''s Prolic ...--■ 

Oto-niassi'ur, 1 lar.i-machine - - - - - 

Supernunierarx' Aiirielos . . . - - 

.Mal-ile\(.4f)pnient of l-^xtx'rnal l"ii . - - - 

Malformation of Mxtern:il liar - - - - 

IL'cniatonia Anns ------ 

Kodcut riicr (jf ICxtrrnal ICar . - . - 

Papilloma of External Mar . - - - - 

Supjiuratin;-; Cyst of LobuU; - - - - - 

Ketro-aiirii ular UiTiiioid Cyst - - - - 

Honu' ("irowth of Aiiri( U- . - - - 

Asper>;illu-- Xi;-;cr Fruit . - . - - 

Hyperostoses and T.xo-toses . . - - 

Sarcoma of 'rem])(i;,d llour - - - - " 

Acute Mastoi liu> : Projection of 1-ai Downward- and 

I'orwards - - - " " 

Caleareou-. Doiieneration oi tlie r\-mpanii Membrane 
Di.r.;iaiii illnstratin',' tlie Inlluenc e of Adenoid \ e'-;etat ions 

in tlic Xax) ])l]ar\iix on Supp!iiat;i n m Middli; l-.ar 
Perforation of M.-mbrane in Posterior Superior (juadrant 
Peiforatiun e.f Membrane in i'()-ti>rior Inferior ijuad.iant 
OtitH Mo;lia Suppurati\'a : Comjilete I)e>triiitiou of M 71 . 

with Cicatrization - - - - - 

Total Dc.itnutiou oi Membrane and ILmdl- ot Malleus (I.eft) 
l'i(.fe-~or Hartmann'- Attn Cannula with ISall Syringe 

attached ------ 

Aural I'oh']nis ]iro'rudinL; tiom Meatus . . - 

Verv Mxteusne Chdlosteatoma o! Par, cau-m- Comjilete 

Absorption ot Internal ICar, openim; up Lateral Smus, an<l 

eausin:^ Death 1)\' Pvannia - - - - - 

Diagram showini,' the t^vo Driver Ossicles shaded to sliow 

the nu>ro usual Sites of Caries - - - - 

N'ecro^i^ of the Lab\rinth - - - - - 

Outer Surface of Temporal I'.imc of a I"(iur-vear-oM Child. 

shuwur^ Xecrosis oeer the Site ot Ma-toid Antrum 
Preparation .Iiowiul; the Handle of tiie M.dleiis bound down 

by Cu atnci.il I i--iie .dter (^'--^al ion of Clu min SiippiiratKjn 
Citiiiei ioi luLiodiit m^ .viliiici.ii i yilip^nic .\icir. ; .rar.c.. 



I'AGE 

52 
71 

72 
75 
76 

!S0 
81 
82 
«3 
-^4 
86 
87 
88 
89 
93 
97 
i^>5 

122 

138 

151 

13- 
153 

134 

137 

162 
1(4 



169 

171 
172 

173 
178 



KIC. 

55- 

5(>. 

57- 

yj- 

bo. 

(ji. 
62. 
b^. 
64. 
65- 



66. 

67. 

6S, 
69. 

7(1. 
7'- 

7-- 



7t- 

lb. 



LIST OF [LLUS"RATIOXS 

Incus Curette ---■""' 
Showinu Trephine Centres for Operations in Otitic Intra- 
cranial Lesion-- --•"'" 

Lalnrinth Gout;es ----'' 

Mastoid Gouge --"■'' 

Chi-^e! Points -----■' 

Pus->earchfr .-•---" 

Left l-:xternal Meatus, showing Spine of Ilenle 

The Incision for tiic Radical or Complete Mastoid Operation 

The Earlier 3ta-c of fhe Radical M.Tstoid Operation - 

The Antrum Opened. ------ 

Section of Left Temiioral ISoue showinc tlie Ca\-itv ot the 
Antrum and its Kelationship to the External Meatus. The 
Cax'ity is unusually large . - - - - 

Vulcanite Shield for retaining Dressin'4 on the Aural Wound 

after Mastoid Operations - - - • " 

The Line of .\uthor's Incision employed in Operations on the 

Lalivrinth ------- 

Tile Compklcd Radical Mastoid C>peration - 

The .Xntenor and Posterior Limbs of the External Canal, 

which are fclUiwed up into the \'<'stihule - - - 

The Completed Operation . . - - - 

Showing OpeniUL! of Cochlea in total Labyrhithectomy 

Double Curved Labyrinthin- Curette for cleaning the 

\"estibule and Ampulla; . - . ■ - 

lluok for ascertaining Depth ot Antrum, and Sott Iron Probe 

for tracing Semicircular Canals - - - - 

Leiikaimia : ♦ion of Cochlea, Lowes"; Part 
Section ot Cochlea, higher up than Fig. 74 - 
Section throiiL:h Horizontal Se:nicircular Canal 
Section of .\pex of Cochlci, showing Leukaemia Clot com- 
meiii-'iig to Cirgauizc . - - - 



Xlll 

199 

203 
207 
20S 
200 
210 
2 I I 
213 

21 S 



221 

230 
231 

23:: 

23-t 
23.1 

2,^3 
2? 4 



I! 



■i 



PLATE I 
ACUTE CONDITIONS 

I. Right tympanic membrane in early stage of acute otitis media, 

showing enlargement of vessels, loss of lustre of membrane, 
swelling and redness of handle. 

2 and 3. Strise of the membrane ight and left, cfter attacks of acute 
otitis media, which have subsided without suppuration. 

4. Acute otitis media : collection of pus in posterior superior quadrant 
causing pouching of the drum ; spot of pus exuding from perfora- 
tion. 
Acute tuberculous otitis media : bulging of whole posterior seg- 
ment, which is dull and with enlarged vessels coursing over it. 

6, 7, and 8. Haniorrhagic otitis media of right tympanum, 
g. Acute serous otitis media in gouty subject, showing excessive 
vascularity. 

10. Acute serous otitis media, showing dark line at upper edge of fluid, 
which is slightly too dark in colour. 

II. Rupture of tympanic membrane (right) ; small perforation at tip 

of handle from direct violence. 
12. Acute otitis, with formation of sanious bulla in meatus, vvhich is 
contracted bv exostoses. 



li 



( To lace Plate t , />■ I. 



PLATE I. 




i 
I 



PLATE II 

CHRONIC NON-SUPPURATIVE CONDITIONS 

I Left tv.rpank mcmbram- : much retra. tion of malleus directly 
■ m^vard ; cone of 1.^1^ almost absent ; crescentic margin of mem- 
brane much thickened. 

2. Ir--' <;ular thickening of the drum. 

3. S.iowini- irregular retractitm. 

. . o and 7. Iiregular local rctra>t,ons of membrane. 

t. Handle appears to project beyon.l the vertical Ime ; long process 
of incus visible posterior to malleus. 

9. K xcessn e retraction of malleus, so that it lies against the posterior 
fold here very white, prominent, and distinct. 

10. Distension (aenal) of lower quadrants of membrane, the upper 
being calcareous. 

, , p,-.ten»on (aerial) of lower ami posterior part of membrane alter 
l.mi; employment of auto-in'lation (Valsalva's method). 

,.. Calcareous .legeneration of tvmpanic membrane, i-^volving pos- 
terior segment, ami a portion of anterior superior quadrant , tht 
remam.ler of the membrane irregularly thickeue.l. 



r r^ ral/.n,: f/.tlt I 



PLATE M. 




R , ( ' : N > T 



I'l.AlK 111 
CHRONIC SUPPURATIVE CONDITIONS 



n-tiou bflun.I inrinl.i\in.> ,ii upl^''' ■""' ^''^'^ 



rotuiulum aif M-iMr ; antmcv muiuiU .al.avrou-. 
2. IVrforation in inftTidi -f^nu'nt. 
^, Ch(>lesteati>inatou> < dU' vi 

part ; clue to oUl suppuration. 
4. Cranula'ti.ms tillm.L; anterior sr^nifnt ol tvnipani. .avhv 
=; S, ar niiinlirano. rii cnl. 

,; IVstrn.tum o, i„l,r„,r ...nirnt an.l al>o of po.trv.or Mip.r.or 
;,uadn,nt lua,l of stap.s, sta,H.d,u. t.n.lon, Wnr.U. rotun.lnn,. 
ami iironiontorv \isiblf. 
;. l',.rtoratu.n ,n po.t.-rior M.nu.nt : .tap,->, >tn,H..liu> t.-u.lon. ami 

tcni'stra rotuuduni txposcd. 
>. perforation ni anterior mlmor -cmn'nt 
,i, rci-foratmn in po^tirmr 11 

,,, ,v.,i!n'!aM>nia>lu-apm.ir>ni,.mbran..,u,tli,nial)penau;..nspolvpi'S 

Iianiiinu thror.uli. 
., ,,„! ,,, l.,.rforat,.,ns in St.rapn, U^ m.n.laan- ni .:, tin- remains 

,,| the lira.! .;r..l ne<k of t!.e r,:all. i>- .:r. -■-n. 



inferior M-in. nt ;ene>tra rotundun, 



[To l«iiow ri,it( II. 



PLATE III. 



lo^tra 



l.:i( k 



purmr 
nihiiiK 



1, iinil 



(liiiii 



jlypiis 



em.'iiris 




I'lalt II. 



PLAli: IV 

TYMPANIC MEMBRANES-PATHOLOGICAL 

CONDITIONS 

, Ki*.,.™,.,™.«».e,, ;.«. ^;-;:--,„, ,„„„„,„.,„ „. 

2 Leit membrane very Lnp,or„cu, 

acute tubercular f^^^'^ ^^,,„ ,,„,,,, ,,nan. 

4. Left membrane, .ha^^^n' ^'"'^^ ui the trmpanum xvh.lst 

the malleus from vK.lent .listcnMon 

7 A local imlraNvm« of the lelt txmp.ui. 

lic'^''^' , 1 , 1 ;,i ^-prti( al and broken 

g Kight membrane : n.allcus .Iraxvn back and n,, xert.cal 

' 'cone of Hght, .entra. depress,on of --^-- ^^^^^^^ ,,,, 

xo .n<l ... l'>nk reflex m case of otoscleros.s . r.ght bch n 

,n the reuion of the foramen ovale. 

12. Stria in membrane, .ause undetermmed. 



To fclUm i't'tl' '"■ 



CllAPTKR I 

A BRIEF DESCRIPTION OF THE ANATOMY OF 
THE EAr 

The external ear. or pinna, is iorniea of fibro-cartikiKe covere 



by skin. This fil 



)ro-eai 



tilage is thrown into fokL of consic 



ler- 



able irregu 
tlie purpose 
the extern 



laritv in different in(livi(Uials. Tl\e>e folds serve 



;)f catehing an<l dftlect 



UlL' St 



untl-waves towai 



■ds 



,al nieatus. and in part diminish the risk of insects 
xternal auditory meatus. The 



hnding their way into tin 



small 1 



irportion of cartilage in front of the external nuatus 1 



las 



for its princii)al function that of preventuig 



prmcii)ai mncuou ih-il ... .... - ^ the sound-waves 

thus deflectc'l from being lost. 

The pinna, as we have remarked, is covered with skm and 
■utaneous tissues ; and at its centre is folded upon itself ; 
1, the edges, although they come into close apposition, are 
not continuous, and a cleft is left at its upper part, the two 
edges being united only by fibrous tissue. The outer point 
of this I le^t ;,ppears at th^^ .i-tut edge or surface of the tragus. 
\ cartilaginous tube is thus formed, which is attached to the 
roughened surface of the outer part of the temporal bone, 
and forms the outermost portion of the external auditory 

canal, or meatus. 

The external auditory meatus is a cartilaginous and bony 
tube about li inches long. Its external or cartilaginous 
portion is rather over ^ inch in length in the adult. The 
continuity of the cartilaginous tulK^ is interrupted by two or 
three irregular vertical clefts, which are known as the fissures 
of Santorini. The inner or bony surface (.f the canal, which 
aveVages in the adult slightly over h inch in length, is con- 
tinuous with the cartilaginous meatus, and is closed at its 



^ ' >.■< At 



^ 



2 HAXDnnoK or diseases or the ear 

inner extremity by the tympanic membrane. The bony 
meatus itself is (leve]o]H'd principally fiom the tNinpanic 
ring (Fig. 5). 

The greatest diameter ol the external auditory iiuatus is 
the vertical one. Taking the canal as a whole, it is at its 
narrowest at the external orifice, beyond whicli the tuhe 
immediately widens, to be again constricted a short distance 
ht'vond the junction oi the cartilaginous and osseous portions. 
This jiortion. where the narrowing occurs, is termed the 
isthmus of the meatus and here the canal is distinctly smaller 
than at any other ])ortion except at its outer extremity. 

The general direction of the meatus is inwards and for- 
wards. The floor is raised in the bony meatus, thus forming 
a general convexity of the floor upwards. The curvatures 
in the external meatus serve the purpose of ..iminishing the 
risks of damage to the inner I'ar which might otherwise 
occur from the direct im]>.ut of vio-: nt sound or air waves 
acting upon it through the chain of ossicles. 

It is on account of this curvature of the meatus that, wh.en 
one proceeds to an examination of the drum, or tymi)anic 
membrane, the j.inna is drawn upwards and backwards, m 
order to make the canal suiticiently straight *■-- ^' "am the 
necessary view of its innermost parts. 7h .raightening 
of the meatus is jiossihle by reason of the presence of the 
fissures of Santorini. 

Immediately external I0 the drum, or tymjuUiic mem- 
brane. The floor of the meatus di]>s downwards, forming a 
depressiiiu of variable depth whi'-h is termed the inns of the 
meatus. This deiiression in tlu floor of the meatus is of 
great ]i'-a(tieal importance, as it i> not j'ossible 11 all cases 
thoroughlvio \iew th nottonni the Minis tlirou,L;h an ,mral 
speculum, ar.d s,aall . ..'Mgn bodies or inse( t^ may theretore 
occasionally lie therein undetei ted. 

The walls of the external meatus are ol uuecinal length, 
the llonr an<l .interior udls iuing h.ng •■ than the nest.rior 
and superior. This lUKiuahty r. ^ults lr(im the obhfpie 
position of the tymjianic membrani'. whieh does not oe(r.i)y 
a plane at right angles to the general direction of tlu ( .iiial. 



iJRIEF nr.SCRIPTIOX 01- AX.irOMY UI- r.AR 3 

The external inealu.s is lined with >kin. whieli is contintions 
with that of the pinna, and near its Drihee are eomnKjnly 
found a number of hairs. These hairs are very fine in the 
young and the ftiiiale. heeoniing eoarser and lont,'er as age 
ad\ances; one observes a large number of small orifices 
ojiening into the external meatus, which are the mouths of 
the eeruminous ghnvi^. These glands, although cliieffy 
situated in dir eartilaginons me:i1us. are usually found 
sparsely scattered in that portion of the .-anal which we have 
referred to as the Jiony or ossious portion. The hairs serve to 
protect the tympanum by arresting the ingress of foreign 
bodies or inserts ; while the wax. orcirumen. which i- Me':reted 




FU.. I — RIGHT MASTOID. 

SH , I'ostcnor mcat.il spine, or spine of Henlc ; CM, cartilaginous 

meatus. 



bv llie glands alreadv alhuled to. en att'S a slightly sticky 
surface, to which dust ami small j)articles of matter adhere, 
and at the same time it binds together shed epithelial cells. 
which, together with the wax. are conveyed outwards by the 
mo\'inicnl> of the lower jaw. 

If the outer >urfa'' • of the dried temjioral bone be ex- 
amined, thi re will usually lie found at the upper and posterior 
jKirt of the Imny external au<litory ..leatus a small spinous 
process, with a slight depression iudiind it (Fig. i). 

This spinous process is known as the spine of Henle. or 
the ])ostrrior superior imatal spine, and in the earlier days 
of aural surgery w.is consideu il a most important anaton ..al 



4 n i\i)i!Oi)K ()!■■ msr.isi:^ or rur- f.ar 

l.mdmark witli regard to (ipcrations on the mastoid antrum ; 
whilst from the malar i)rocess of the l(.'in])oral bone two ridges 
are olwerved running backwards, the superior (1 which sliould 
l)e remembered as formhig a useful guide to the ajjproxi- 
mate upper limit for oi.eralive procedures on the nuistoid 
antrum, unless it is desired t(» open the middle fossa of the 
skull. In some skulls the sqiuimo-petrosal suture is visible, 
and the temporal bone may even remain di\ided in tw() i^arts 
at this dure, and when there is, suppuration within the 
mastoiil and such a suture exists, pus may always fmd an 
easy exit towards the surface. 

The cavum tympani. tympanic cavity- or middle ear. is 
of an irregular shape, having measmxinents ai)pr()ximately 



A.a.A 




S.T 



FR. 



PIC J __ij;-v;er wall of tympanum (right). 

AaA Adi! ad antrum; /./, lonR process of incus; FN. Fallopian 
canal; 57, stapedius tendon; 5, stapes; P, promontory; i-A, 
fenestra rotunda. 

I incli in dejith. ,' inch in height, and \ inch in width. Its 
pnncip.d external Ixnmdary is the tympanic membrane, but 
the cavity extends in all din'ctions beyond the membrane. 
but chiefly ujmards towards the roof, forming the so-calli'(l 
attic. 'Ihe u]']>er wall, or roof, of the internal ear is formed 
by a thin l;iver of bone, which is termed tlie tegmen tympani. 
'riii> lionv I'late is o( casionally incoinpletilv ossified, the spaces 
left m the bone being iiK rely filled l>y fibrous tissue, so thai 
in such instances there i> lietweeii the middle e;ir itself and 
tile dura mater only a tliin layer ot muco-periosteum, an<l 
through the deficiencies thus left S(-]^tic matter in the middle 
ear maj with relative t.ise find an lutry into the middle (o:,sa 



BRIEF DESCRIPTION OF AX ATOMY OF EAR 5 

of the skull. The floor of the cavity is formed by a thin 
jjlate ui bone, which at the same time forms the roof of that 
hollow in the lower jiortion of the temiioral bone which 
receives the l>u. '' the internal jugular vein. 

Tlie anterior w.ill of tlie tympanic cavity is formed from 
above downwards by the following structmes : Firstly, by 
a small ]iiece of the temjKjral bone, in which an oi)ening is 
occasionally observed, which passis directly int(j a scries of 



/ 







VIO. J. VI-RIICAI. Si:CH()N TIIKOCC.H KIC.llT riMlHiKAL lidNT. 

U, I inl>i) ; /, iiu us ; /', iirnniDiituiy. 



ceils in the jii iiiius |)(irti<)n. 'I'iicse cells, when present, often 
extend to the \-ery a]icx of tiic petrous iioui'. Next, one 

tiii'ls the ixiny wall ot the carotid i an.ii below wliich is found 

tile internal oritice (jf the luistac hian tid>e. 

'1 he jiostcnor w.dl ol the c:i\ity is foiincd liist li\ the 
aditiis, or tlie cntraiuc uito the ni.'-,toid antrnm, and below 
simply by a j-ortion oi the teiupnia! \.uiu-. Inuucdiatcly 
below the .idilus ,1 small, hollow projection is observed, 
wliiiu c in hie issues the teiuloii of the stapedius musi Ic. 



6 HANDBOOK OF DISEASES OF THE EAR 

The inner wall of tlio tympanic cavity is formed hy numerous 
important structures (Fif,^ 2). A prominent ridge of bone .• 
observed both al)ove and behind, v runs hall-way across 

the wall. Ihis is the Fallopian . which in the recent 

state contains the facial nerve. Antiriorly to this one 
observes a small (de\ation. which is hollow, and perforated at 
its a])ex. through which in the re.ent state passes the tendon 
of the tensor tym])ani muscle. Fxlnw the Fallnpian canal 
one observes an o\al orifice— the fenestra ovalis— which in 
the living body receives the foot})late of the smallest of the 
ossicles— the stapes — the edges of this footplate being con- 
nected with the surrounding bone by ligamentous tissue, and 




Fin. A, PurlAKMlnN SHOWINC. ATTIC AND CAVt'M TVMI'ANI. 

Mr. 'rvmi)anii iminliraiK' ; HM. hanille of malU u.. ; /.'.I, ba^t- ol attic ; 
M. head of inallrus, >uii (uiiulfd hy irregular icllular spates caused 
by rccliipluations o! the mucosa. 

it is said that then' is al>(> present a tinv synovial -.i.-. In Mir 
drictl bdur this ov.d dptniug ((intnuinicalcs dufctly \Mlh 
the vestiiiulf. At the lower and jiostcrior jKirt oi the inner 
wall is another foramen, roughly triangular in form known as 
tilt' ftiifstr. ndunda. Anteriorly In ih'' Inustra ndiinda. 
and below tlie teiiestra dvalis the internal wall (d the tvm- 
paniim pi-ojeets pri>inineiitlv mitw.iids, liuniing a voiiinled 
clevatitin. .iiid I0 this elev.itioii. uhi<li is tdrmed by the lust 
part ..I tlie lowei (Oil ol the ((i(lilea. the title (d the ]ir(iiiinn- 
tury h.is been given. 

[he small pyrainitlal process from whi< li the stapedius 
tiiiddii i>su( s may t.ireiy be seen tluring liie 



BRIEF DESCRIPTIOX OF AXATOMY OF FAR 



The attic is that jiortion of the tympanic cavity which Ues 
above an imaginary hnc drawn horizontally through the short 
process of the malleus, ami which contains the head and 
neck of the malleus, together with the body of the short process 
of the incus. 

The cellar is that portion of the tympanic cavity which lies 
at a lower level than the lower jiart of the external auditor}' 
meatus, and i> very well shown in Fig. 3. 

The whole of the inner surface of the tympanic cavity is 
closed in the recent state i)y a thick muco-periosteum, which 
periosteum is continuous on the upper side with the peri- 
osteum of the Eustachian tube, and on the other with that 
lining the larger accessory cavity of the tympanum, this iieing 
continuous, as will be seen later, with the fibrous jiortion of 
the tympanic nuinlirane itself. The contents of the cavum 
tympani are ihe ossicles— viz., the ma'leus. incus and stapes, 
chorda tymjiani, tensor tympani, and the stajiedius tendons, 
together with some small vessels and nerves. 

The Internal Ear, or Labyrinth, is divided into two distinct 
portions— an anterior part, or cochlea, and a posterior part, 
the vestibule anil semicircular canals. The former, which is 
su])plied b\- the terminal lilnes of the auditory nerve, forms 
itself tlie end organ, and it is this portion of the lat)vrinth 
which is entirely concerned witli the conveyance of sound 
impressions to the brain. 1 he latti'r. which is the end organ 
of the co-ordinating fibres of the eighth pair of cranial nerves, 
is concerned solely with the maintenance of the ecpiilibrial 
functions. 

Ththe two portions, distinct tiiough tliey are in function, 
are intim.itely connected by a junction of their lymph sacs, 
so ill, it, unless tliat juiv tir'U be jierinaneutly or temporarily 
interfered with, ((iiulititnis of tlu' en<lo- or pendvninh 
invol\inL; till' one portion must of necessity affect the 
other. 

The nieinbiMiioiis labyrinth itself is eiic1(i,,,fil in a itony case 
of tai' l;h .ih t density tiian any otiur bone, excejit that ol the 
low. 1 j.iw. ,iiid is situated principa'ly iietweeii the inner liony 
^\all ol tlie (.i\u!ii tyaipani autj the deejiei- iiortioiis of tlu' 



8 HAXDDOOK OF DISEASES OF THE EAR 

toniHiral Ixmr. Th(> imimnnKn-y. as wo liavc mentioned 
belorc. is fornuMl liv tln' tnst turn <if the corhlea. ami the 
foranu n (i\-ale oj^ns din ctly into the vestilmle. 

The iiiciP.lnaiKnis labyrinth itself consists of an onter 
fibrous eoxfiin.L;. es])f(ially in its ]iostcrior part, winch ]no- 
tects the inner or ].hy>iol(i{,dcal portion of certain of the 
structures. 

The external Sfniicireular canal which is the only one to be 
obscrwd din-ing operations <.in tlie niastoicL lies nnniediati'ly 
abovi' the Fallopian tube, which contains the facial nerve. 
an<l is plainly seen as an o- il whitish projection on the inner 
surface of the aditus durin.L; the i)roj^'ress ot the radical nrastoid 
operation. 

The ]>osti'rior ami >up<'rior canals are not exposed duriiif^ 
most operations, but their relative positions are slmwu in 

Fi}:. If'. 

.\ \ ( r\- imiKirtant structure is the aqueduct of the vistibulc, 
a Itne lilndiis \\i\>v coimecte(l with the (•ndo-iymjihatic s,;c. 
and which in the n'ccnt state has its extninity lu'tween the 
layei. ef the ura mater on the ]iostenor surla. e of the jietrous 
bone and anterior to the lateral sinus. 

'Ihe whole ot th- labyrinth recei\-es its blood-sujiply liom 
one sin,L;le aiievy. and tins vessel alter f(etal lite has no 
anastouiosiN. from which it lollov^s that any ol'stnu tic)n in 
or affecting this ve-^-e! must U a\e the internal eav without an 
etticient blood-supply. 

F'or li 11 details oi the anatomy, histology, and jihysiology 
of the ear the reader is reMind to the tiNtbooks on anatomy 
and I'liysiolo^y. 

The Ossicles. -'I'he malleus, which is the largest ot these 
little bones. IS (iuided anat oiiiii ally into a luad. neck, and 
1i:,im11, . ■jh,' heiid aitunlates with the second largest bone, 
the iiK us. Below the head is a constrieti d |)ortion the net 1-: 
- wliiih ]iasses mto the long han<lle. At tlie imietion ol the 
liaudle with tlie neck are seen tw* jMoeesses ot bone, one 
projecting outwards and lorwards. known as the short pro- 
cess, or jirotessus luexis ; the other <lirec ted lorw.irds ami 

;,-..._ .-,1.. 4.,,.„r.l 1 ;., tl... (...(11.. (liw.Tic.li till' ( '.l;i-.eri:iI1 



r.niEF DESCRIPTION OF ANATOMY OF EAR g 

fissure, the iirocissus gracilis. The latter is represented in the 
iiilult liy a minute \wm\. of hone, to which is attached the 
ant< riiir li^'anient. The liandle is directed nearly vertically 
(liiwnwards. and is intimately connected with the ineinbrana 
tyinjani. The head of the malleus is attached to the I'-of of 
ihc tympanum l)v ;i ligament termed the suspensory liga- 





FIG. 5. TYMPANIC KING, AND OSSICLKS AT HIKTII. 

I, rvinpaiiit riiif,' ; j, incus; 3, jiroci'ssus gracilis; 4, malleus; 

3, stajK's. 

ment (Fig. 12). The incus consists of a l)ody and two pro- 
cesses, ihe l>i)(l\- articulating with the head of the malleus, 
to which it is united l)y a capsular ligament. The short 
process jirojects almost horizontally backwards, and articu- 
lates with the flour of tlu' jiassage from the tympanum to the 
antrum. The hmg jirocess descends parallel with the handle 




Fir,. 6.— -THE ossici.i s (uif.iirl ,\UTirci.ATrn. 

[ lie NLipi s ha-, lallcn out of | ■ ■ < ; it slioiih! bu .iliiiD^t at a rit;ht an^le 
to tlie loii^; pro'a.s^ of the incus. 



of Ihe m.illeus to the level of tlu> centre of the fenestra ovalis. 
w hi rr it articulates with the head of the stajx'S. to which it is 
attaciied l)y ;i caiisular ligament. The third ossicle, or sta])es. 
whirli I liisrly resemliles a slir'up. consists of a f(iot]ilate. two 
crura. .1 neck, and a head. The footphue articulates with the 
inner edge of the fenestra ov;ilis, to which it is attadi'd hy 
ai: annular iie.Miuni. Of the crura the anti-rior is str.UL'hter 



lO 



HANDnOOK OF DI! SASES OF THE EAR 



and sliortcr than the posterior. To the posterior part of the 
n(>ek of the stapes is attached the tendon of the stapedius 
muscle. Tlie footplati' of the ^.tapes moves hinge-hke in the 
oval window. f(.»r on account of tlu- greati-r laxness of the 



c.r 



FR 




^.T. 



pI^-,. -. DISSKCTION- SHOWING THE RELATIONS OF THE CHOKnA 



TVMl'ANI AND THE OSSICLES. 

CT, Chorda tynipani ; .S', stages : ST, stai)iHiiu> 
J'h'. t(•IU■^tI■a idtunihi. 



tiniliin ; 




PIG. 8. DIAGRAM OF THE. TYMPANIC MI.MERANE, SHOWING 

VAUIorS NOHMAI. ANO AUIIITCIAL I'OINIS. 

I, CdiK' of li.ulit ; 2. iinilx) ; }. hanillc of nialU-iis ; (. short process ; 
5, anterior liL;aiiunt of iiu'iiiliraiu' : (>, po^lrrior lit^anu'nt of nicin- 
i)ranc ; a c, anterior segment : <i. anterior siijxrior inKuhant ; 
c. anterior inferior ciuaihant ; b d, po.-,terior se,L;nu ut ; '-. po>teri(ir 
superior ([uadrant ; </, posterior inferior (lu.ulrant ; ~, slnapneU's 
membrane ; v, stapes ; ,v, Xnv.'i process ol luc us. 

annular ligament in the anteiior part its gr.':)tcr rnntre of 
movement lies anteriorly. The ehonla i\nipani nerve (Fif,'. 7) 
issues from the posterior v.all of the tymjxinum. and cressiuh- 



_.. 1.. t ,... 
4"' -J '■'■"■ '■ 



.1 (,, (!>.. 1, 



II ir J ir( I 



,t 11 



BRIEF DESCRIPTION OF ANATOMY OF EAR 



II 



incus, internal to the handle of the malleus, above the tendon 
of the tensor tympani. and leaves the tymi:)anum in company 
with the anterior ligament of the malleus by way of the 
Glaserian fissure. The ossicles, tendons, and chorda tympani 
nerve receive a covering of mucous membrane from the lining 
membrane of the cavity ; this disposition of the mucous 
nieml)rane forms irregiilar folds and bands within the cavity. 

The Tympanic Membrane, or Dmm, is a fibrous or peri- 
i.sti'al membrane which, from the obliquity of the canal, faces 




FIG. 0. — DISSECTION SHOWING THK TKUIOSTEUM {p) OF THF. EUSTACHIAN 
TUIU: CONTINI'OIS WITH MI^MIIRANA VROl'RIA OF THE DRUM. 

cc. Cirotid canal (with probe) ; /;', jugular fossa ; al, anterior ligament 
of malleus ; »ia. mastoid antrum. The second probe is in the 
Eustachian tube. 



dowii> .uds and forwards, forming an angle of 140° with the 
superior ;"ul posterior walls, and an acute angle of 30° with 
till' anterior. Its general sliajjc is oval, tlie longer diameter 
l)eing the vertical one. and it presents a general concavity 
outwards. The handle of the malleus numing almost directly 
downwards to the centre of the meml)rane. divides it into two 
unequal ]H)rtions. tlu- anterior of wliiih is the larger. The 
conra\ity of the drum is dee])est at tlie tip or fni' ind of the 
liandle. The centre of this small and deeply-depressed area 



12 



HAXDIIOOK Ol diseases OE THE EAR 

The lui'inhr.ina tympani itself consists of three layers — 
an external culane(jus. continnons with the skin of the ex- 
ternal nieatns. a middle layer oi Ubruiis stnictnre, and an 
internal layir of inuedu.^ nuinhrane nkiitjeal and eontintions 
with that ol the tyniiuuue cavity. The middle layer, known 
as the niemhrana propria, ha- radiating and circular hhres, 
the radiating passing Irom the periosteum of the handle (>f 
the malKris to the periphery, whih- the iircular are found only 
in the outer portion. Tlie lihrous layer is insi'rted. as it were, 
' rolls tissue, which is received into a bony 



into a linn ring ol lil 




FIG. lO. TYMr.\NIC MKMrKANt. AND ANIIUIOK HAM- Ol- F. lSTArHI.\N 

TUBE, SHOWING THK I'ERIOSTTaM (M THI I.AITI.K lONTINCOl'S 
WITH THE SUBSTANCE OF THE FDK.Ml.K. 

groo\-e at the inner extremity of the exti rnnl meatu:^. t(>rmed 
the sulcus tymi'anictis. This groove is ^ituati'd .almost 
within the tympanic ca\-ity. as seen in the dried l)on(\ Through 
this lihrous groo\e the niemlirana ].roiiria is continuous with 
the periosteum ol tlie external meatus on the on.' side (Fig. ()). 
and with that o! tlie tympanic cavity and the luistachian 
lube on the otlii r (Figs. (). lo. ;iud 15). The handle ol the 
malleus i> iniim.ittlv conne( ted with the I'luous layer of the 
drum at its lowest ]>.irt. hut in its npp.er two-thinis t!i<' hhres 
of the drum for the mo.>t pari pa^s (Xtevnal to t. thu> pi'r- 



I'.RiF.r Di:sch'i rriox oi- .wmomy oi- n.iic 



13 



niitting a certain amount ui niohility of the ]M»,ttvi(ir part ot 
till' ilnini without a corrcspomlinf,' niovi'iurnt on the part of 
ilic nialKus. At the inner extremity of the external nu^atus 
the wall is (Icfieient ahove. Thr sjiace wliieh is left is termiil 
the notch of Ri\'ini. ami in the receiU state i> Ini'lf^'dl 
(Aer hv irregularly interlacing bands of fibrous tissue. This 

/I 



R.C. 







I-le.. II. VKRTICAI. SKCTION THKOCCIi RIGHT TKMl'OKAL HONK. 

.1.?.!. A'litns ad aiitruni ; KC. radiatinc; i cUs (round antrum) ; VSC, 
external scniiciri ular canal ; .S.SC', superiDr soniiein idar eanal ; 
i' in l-'O, stapes in fenestra ovalis ; IM, internal meatus. 

portion of the dniin forms Shra])neirs membrane, or the 
iiiembrana tlaccida. and is not ac tually jiart of the tympanic 
niriiibrane pro])er. 

The tympanic membrane i< divided, for jwrposes of descrip- 
tion. l)y an imaginary line drawn through and in coiuinuity 

Wilii liU iutiRiii.- i)i iiR- lluliieu^. liiio iiu aiiUimi inni pti.--u.iiul' 



,, n.].\i)i:()()i< 01- nrsi:.isi:s of riii: i:.iR 

sr^iufiU. Thrse segments arc siilnlividrd hy a line >lra\vn 
at right angles to the former through the tip of the malleus, 
thus dividing each segment into two. which are known re- 
spectively as the anterior superior, anterior inferior, posterior 
inferior, and posterior superior (piadrnnts (Fig. 8). 

Besides the handle of the malleus, the following features arc 
to be observed by inspection of the drum • 

In appearance, the membrane is in health i>early grey, but 
considerable variations are observed within jihysiological 




FIG. i; 



-TEGMENTUM TYMPANI REMOVED, EXPOSING MALLECS AND 
SUSPENSORY LIGAMENT {SM). 



limits. At the upper part of the handle, projecting fonvards 
and outwards, is a small bony process. This is the processus 
brevis. or short process of the malleus, which in the healthy 
subject appears white. Above this jioint lies Shrapnell's 
membrane, while from it run two curved bands with their 
concavities downwards, the anterior and posterior ligaments 
of the membrane, which form the ujiper margin of the drum, 
and limit Shrai)neirs membrane below. There is seen spread- 
ing forwards and downwards triangularly from the umbo a 
light rellex, called the cone ot light, which owes us origin to 



r.Hiiii- i>i:sch'!i'r/(>x oi' axatomv (U- i: ar 15 

llir ]M ( uliar concavity of tlu' nornuil drum, for light can only 
lie nllictrd hack to tlic oI'ser\ • from this small triangular 
ana of tlic drum ; its extent shoulil be from the umbo almost 
to the iieri])hory. 

The Antrum, also called the mastoid or tympanic antrum. 
is the most regular of the pneumatic or air cells found in the 
mastoid process. It is situated jjosterior to and at a slightly 
higlier level than th^ main caNdty of the tymiianum. with 
wliiih it is coimectcd by a passage, the iter, or aditus ad 




C.!l^ 



FIG. 13. — SI CTTON THROl'GH SCLEROSED M.\STOID TROCESS. 



antrum. It is formed in the f(etus l)y the junction of the 
squamous and petrous portions of the temporal bone, and 
exists liefore tlie mastoid -process is developed. Its size in 
the f(etus and cliild is proportionately very large. And. 
excepting from its situation in the adult, the term ' mastoid 
antrum ' is not anatomically correct. The aditus. or passage 
into the antrum, opens into the tympanic cavity at the upper 
{lart of its jiosterior wall, the facial nerve passes from before 
liackwards at the tymi)anie end of its floor, and the external. 
or nnri/'.niriai .iiihaueuiai. cauai iiiako a pioj'ciion iorvsardb 



i6 



]i.i\[>n('(>i< " 



/■■ DISHASHS or Tin- F-Al^ 



,„, „n asl.Kbtly P..st.n.n- plane tc U- l>n,a > . 

lnUat,h.-.ndof.luMlH.o,l.al.nU,ln^a... m^^^^^^ 

>t - tlu- alult. Tlu. antrum >s --^ ^^^^.^...ution 




FIG. I). 



-Crl.l.lI.AK MASKIH) l'KOCi;SS. 



, lu ,h thr antrum ;thr Other group. NvlK'U 

rusta,luautulH..o,l.a,laprolnOM.^ 1 U ^^^^^^^^ 

^,,,,.,,,,,,,.,,,,,„.,th..tyn>panu..-U^;^ 

llu-uU,us. ^--'-""V ; ih u nun, >.MU.amHt.s 
sUuat.lattl.sam. l.v.la. h > M-- 

.,1 ,,.at unportan.. to nmuMnlur ^}^^^;-;^^^^ ^^^^^ ^^ ,, 
\\u- ra.lKal ..p. ration oi ui.o, ".. 



BRIEF DKSCRIPTION OF AXATOMY OF FAR 



17 



tlu> tynijianic cavity appears to, and does, lay at a greater 
depth from tlie surface than the inner wall of the antrum lies. 
The uses of the antrum and air cells are partly to lighten the 
skull, and j^artly to act as an air cushion to lessen con- 
eussi(;n from loud noises or explosions. The outer Wcdl of the 
antrum is i)laced about 0'6 inch from the surface, and is 
separated from the sigmoid groove by about 0-48 inch. 

The Kustaehian Tul)e is i ^ inches long, is directed down- 
wanls. forwards, and inwanls, and, like the external meatus, 
consists of a l)ony inner portion, approximately | inch in 
length, and an outer cartilaginous portion. The narrowest 




III,. I-. — SECTION (vfrtical) p.\s?;iNr, throit.h tiii: rwuM tymp.xni 

A.NI) .\NIKtM. SIIOWINM TUl; TWO I.AkOl K OSSICLICS IN SITC 

(t, flionhi t\ni|),ini . tt. tensor tyinpini ; s/, sus|H'nsory li^ame-nt 
cit liialicu- , /', piridstoiim ot l-hist.u lii.iu tube. 



part ol th.' i:u>ta< biau tube is at the junction of ilie two parts, 
an>l i> tiiiued the istlimus. The cartilaginous (anal opens into 
tlie naso-pharynx at a level slightly abov that of the hard 
p.ilate. ihc posterior |>art of the cartilaginous wail i)rojects 
iiiuaids tniining an cmineiirc termed the posterior lip of the 
II Mum. just witliin this orilire. and liene.ith some in\-olun- 
tary nmsc ul.ir hl>res. is nonnally found a sm.iU (piantity of 
t.it. ubi. li .issists ill kecpiiif; the sides of the ttiix- in apposi- 
tinp ill,' lube itself IS lined with ciliate.l epithelium. Bihuul 
tli< ostium is ;i (1,,.,) (irpression in tiie side of the naso- 



l8 IIAXDBOOK OF DISFASF.S OF TIIF. FAR 

phannx, Xwmcd the fcssa of Roscuuiilk-r. into which the 
Etistacliian catheter luav be piissed in mistake for the entrance 
of the Eu>tachian tui.e. The tube itself is opened dnrnig the 
process of de-Uitilion. Nvliich enables the air Nvithin the cavuni 
tynijiani to maintain an ecjnal i)ressure with that of the atnio- 
si>here ; and it is npon a knowledge of this physiological fact 
tliat the jM-ocess of intlating the tymiianum. which goes l)y 
tlie nanu' of politzerization, is tniuided. 

The Mastoid Process is not present at liirth. and does not 
acpiire its tyiacal shai)e nntil the end ot the third year, la 




j-lC, i6.— DISSECTION OI- SEMICIRCVLAR CANALS, SHOWINe. TlltlK 
KII-ATIVE roSlTiONS. 

.s- Supciiur ; F, . xt. rnal ; P. j^rM.-i .<,r (a hole I, ■ h>.>i <'ut with 

the lULhlcii). 



the adult it varies nni< h in structure, but its general shape 
is nnuli Ihi same, being roughly triangul.ir. with the apex 
(hr.vuwai.ls. It ((.ntains, I.esides the antrum. ..rtaiu irregu- 
larly distrilmtrd pneumatic cells. toL^etlur witli a certain 
amcmit <>l dipl.i.;. '1 he stru. Imv ..f the mast(.id may vary 
Nvithm xMde hmits. being, on tiie one hand, composed entirely 
oi cells (l-ig. M) ;ind. on the oHk r hand, lorine.l almost 
..,,;,., I. .,1 .1, .„.",. Iwin.- (T'i-. i.il. When thr masidid process 



BRIEF Di:SCinPTIOX OF A SATO MY OF FAR 



19 



is formed almost exclusively of cells, the maJDrity are pneu- 
matic ; and in these instances there is one cell which is fairly 
constantly present, and is fountl at the lower and inner aspect 
of the mastoid proce>s just al)ove the groove for the digastric 




riii:ni 



VIC. '.7. — SIXriON OF Tl;.MI'ORAI, noNi/cL'T TIlRorGII INTKKNAL 
AUDirORY MKATUS. 



muscle. To the presence of this cell is due the fact that, in 
certain inflammatory conditions of the mastoid, ptis is enaliled 
to liiid it-^ way intii the diL,Mstric j^roove. and onwards into 
tlic deep structure of tlir ucck. At other times the general 
structure of tlie ]ir()ii>s resendiles that of the dijilot'. 



CHAFn:K II 

THE GENERAL EXAMINATION OF THE PATIENT 

The Patients Previous History. 

,,ti,„, ana t.. his i.r.vu,u. .lliu.>.>. nu.u ^^ 
vganl to the vav.ous c.xantlK..nata, and any '^l^^^"" ' .^^ 
;.tt.d bv the patK.nt between the i>rst .Kcuvrence o th. an 
tn-ubl. ana anv such general aisc.nUr nuule note -^J^^^ 
..„t of no .ueh n.fornu.,on beu>. torthconung. ^-^^^ ;"- 
.xanunat.on. wUh reference particularly to scarlet f ^. an I 
1 -.na the Ur.t onset ol aeafness or aischarge f.oni the 
rtm in thlw a gooa aeal of h,ht on the natnre ..d 

uLion of the .bsease. l^'l-O-l-l^ al.o 'k- -ule ^^ 
,,,,UH.r tluM>atu.nt n. chiiahooa lu.a been subject a^^^^^^ 

,, ,,,,,,„ for cas, > .ill not i"i-l-"^'>-.l"^'7 „ ' ^ ^ ^ 
i, ,,,i,U there ,s ntore or less .lestrnct>on of on b 

tvnuKUUc nu.nbranes, or o,her s.ron, evulence o p, u 
u.LuHn>ra,unr, an.l vet the patients aenv any kno.lgc 

Ischuge front the ear, bnt cUstinctlv rcnenrbcr th.a tluy 
1,1 ..-n-Lche m earlv cluiahoua the presence ol 

;;;:':;;: -r a;:; '^^ 

':r;on,pleMy forgotten. Nor ntt.t the occurrettn. 

, fn.ment col.1 ana relaxea or M,re throats !,.■ passed h>^ 

;;; Ihl. are acontnton prea.po.n.g cattsc ot no,, M.ppuratutg 

'''';H;::'::aeat-,.,.t,,s,n.,t,. very t,,t,orM,,t.,on, the ,.^^^^^ 

of view of piognoMs that the earliest s,gn o, ,he ueh- ,. ,■> > 
!. ;;:rat..|v.Me,-,nu,ea,s,,,ha..h..herthec,,ah.^^^^^^^^^^ 

.1 n .nv:,ensothea,-,ngornttere.lanya,tuulat. u>..m 

vshelherlheMuiahaaaheaayco.n.nencea to.p..... 



Till-: <;i:.\i:h'.iL i:x.imixati()x of thi-: patii:xt 



onv ov two words and that after somo severe illness or acci- 
dent the hearing power was lost, and with it that of articulate 
speech, ("ases of deaf-nuU ism stihscqiient to disease in early 
cliildliood require to he divided with (,'reat care into those 
dependent on intracianial or labyrinthine lesions, such as 
those following nu-ningitis. and into those due to a probable 
special intlanmiatory condition of the middle ear. causing 
temporary deafness. A fre(|uent origin of this latter form 
is secondary in\-olvenient of 'lu' middle ear during an attack 
of lironcho-pneumonia. In thesi' cases, when the child has 
been thouglit to have suffered from meningitis. e\'en if some 
of the >erious symiitdUis tif meningitis liave been present, the 
aural prognosis is much more 1 opehd than in tlinse cases due 
to genuine meningeal trou!>le. 

Previous Illnesses, it is necessary to bear in mind, ofti n ha\e 
a distinct itithi'iice on the ear. partietdarly should tln' presence 
or al)Sence of liereditar\' or accjuiriHl s\'philis be asciTtaiiied. 
Wheii this dist'ase is hereditary, and deafness presents itself 
as a tertiary le-~inn. it usually In'gins in early life, from the 
age of tweKc tijiw irds, but it may be delayed tmtil young adult 
life. It geueralh- ((imiiK lies alter the appearance of inter- 
stitial keratitis. It is rajud in its course, and the inthience 
of the tre.Ltnuiit aij.ipted to the keratitis a]i[)arently affects 
tlu' course of the aural disease only slightly. Hutchinson's 
teeth and any affect ioiis of the nasal liones. as well as a history 
ot smiffl s. must lie searched !or. 

Gout, Rheumatism, <ach ha\e an effect u] on the car in a 
cerbiin |>roportion of cases. The lU'ist frecjuent inanifcsta 
tion ol gout is to be found in an eczematoiis condition of 
the external meatus ; in cases ol < hronic middle-ear c.itarrh 
the tendency to tiimitus and \-ertig() is greatl\- increased if 
the patient lias a gouty clyscrasi.i, 

in rheiim.it isni the rem> dies .administered lur its cure will 
liii|uentl\- cause tinnitus and dealiuss. the most ini] ortant 
i!l thi-e being the salicylates; and ;! has been noticed :!iat 
where the\ cause aural trouble tluie is already a tendeiic y 
to diseases of t!ie car. 

Awt,^win Cnlnwnrtr. 'II.;.- .t;, ....... f- ,.,4l.. ..iV , .1 . j1 



JIASDlunm OF DISIUSnS OF THE FAR 
t,rnal .ar. and is a prolific cause of dc^dness. vertigo, and 

"'l^fli^nza .K. 1. (o,,,,w.d 1.V l..mn.rhap^^ 

,,v .„pp„ra,iv. <nn,> nud,a. and hy ^snlated ^1-- - tli. 
„.,.t. ,V and th,.Mn turn nm- PV.M.MMO anv of tlu nt a^ 

,,,„i,l l,..„.ns whuli tullnw on M.pimrat.ve chsea>e ol the 
;::;;;,..... lnoU..rea..^non->nppuratn-ecatarrh maybe 
s.tun nr..Avnn.rv.-drainr.sit>elf may follow 

R^idence in the Tropics, ..,.eudly d the patent IK..^^ 

suhne, to at,aek> ul makuaal f. ver. .s ol.en found to luue 
^ Lpor.am luarm, ..u th. progress ..f the non->uppunUne 

;:, :..,fthem,ddleandmm.r..ar. It als.. has a tendeiKy 

towards,!,,, pro.hu tinu of an aU.r.ds.erenonol the.^-u- 

:,.,d^,ith,.xt.rnah.ar.ean>m. an undue aeeumu^ 

;:o,:.rum.n. Apu. .h. h uM.i.l md . no. e.^^^^^^^^ 
v.TV ran. l.m >-^ Mdl tu he lonnd. .>p<.udlv m th. l.n ( (.nnt > 

u,d in ,h. lowdvm, lauds of iMU, and KS...X has an equalh 
;;;;;;:,...> ...feet upnn the ear to that wlneh malaria has m 

'^^Hysieria and Neurasthenia. -In pat u nt. affected with e.th.T 
,,Uh,s. adn.m. nuu-k.d d.ahiess ..i a mure or less siulden 

' ,^ „.„ „,.,v,,u.nt!v oeeur.. In .very .nch instance 

;'';;;;,;;.. auiuiat.li wUlprov. , ha, tlu.re really exists some 

^li-ht form <if aural trouhle, 

■ Climate >s also u.duve,lvn>p.>nMhl. lor nn,,h aural .W.w^^ 

too ,HU.h n.oMur- m ,h. a,mosph,.,v mduenig e;.an uU 
Slates ol ,h. uns,. and, ,.,M,-pl,arvnN thus uidireetly atfe.tmg 
theear,ln-nu,h .xui.s,,,,, ol ,h. udlammatoiy procrssrs up 
„., l.-,M,..l.Kmtul.r. Ih. mhal.tamsotth-hasm.o lavers 
,„a ,;„ la,uls and ,lH,sM>vn,, on Ja^, y sods a,v imudMUon. 

l.kelv to Mitlrr 1,-om adenoids ,h;,n ,hos. hviUK m hiKl^e, ana 
.lvv."r loeaUt,e>. 1 la-se vegetaunus 1. ad ,o dnunnslu d ar,a„on 
„nl. ear. iiSWellusca,av,lMl,han,.s „„,l . xpos. ,h.. mdi- 
viduai ,o., ,;,r.a.r lialalitv t- mtkunma,- v pi-oc-srs u. lUr 

"'unhvgienic Surroundings and muhv muruion a,>pear to 
, ,t .-«„,.. .... ii.. ... i.nt n Is ol mti rrst to 

,..„u-,uker ,h.Lt atrophic vhne.Ms ,s .hHtly n>et v.nh m those 



77//: (U- XI- HAL E.\AM[XATIOX OF THI- PAril-XT 



23 



,l;i>sts exposed to bad environment, and of these cases a 
j.roi.nrtion is comiilicated with ear disease. 

Habits and Occupation must hv also considered as to their 
inlhunce on the individual. Any tendency to excess ni the 
...nsuniption of alcohol or of tolnicco. thongh rarely of theni- 
..Ives likely to be the priniarv cause of an aural complanit, 
,uav certainly be the means of accentuating it. it present. 
ThuM. occup.itions xvhere workmen are employed in tunnelling 
,,-vdi.pn.e to ear affections, if it be necessary, under such 
renditions, to use chambers (_)1 compressed air m cai>son>. 
In the case of workers in coinpresM-d air there is reason to 
b.liev that if due iM-ecautions are taken no evil eftects accrue 
.,, l„ng as the indivi.lual subjected to the increased atmo- 
spheric pressure has a relatively normal ear, including a patent 
Fu.tachian tub.' and an unobstructed no>e. Riveters, who 
;nv expoM.l to almost continuously repeated sounds of more 
ur K,. „ne pitch, are especially liable to aural complaints; 
;Mid with men similarly em].loycd the rontmiious dang of the 
,u,.t;d causes a severe and intractable variety u[ lurvc-cieat- 
„,..s and this does not appear to hv entirely dependent upon 
nrevious slight aural .lis.'ase. though middle-ear deafness 
,l„uhile>s predisposes to it. The same effect is olten tnun<l 
,„ s!„,.,iers. and also in naval and military men. Ordinary 
,„.uiiurcial hie cannot be said to cause deahiess hut great 
menial strain and prolonged anxiety will materially exaggerate 
,uiv existing mi.hUe-ear deafness. This effect naturally de- 
,u nds l.ug.lv nn the temiHrameiit of the individual. 

Injuries. Certain injuries act dire.tly nn llu' tympanic 
,M, niir..m<', causing rupture nl the drum. ( )l these. <liivct 
l.lows on the ..ar. by compressuig the ,iir m the external 
iueatus. are the e..innione>t . anses. Sud.len compression nt 
tl„. .,n-. .siuh as that caused by Imid exi'losions. m the near 
M> iiiity nl the patient has been known to -aiise a like- resuh. 
l,ut It is supposed by most amhonlus that iliis unuM nnt liave 
(Hcurred ha.l the drum been n.-rmal. Mmiigh tin- opnnon 
li,.s heen ably contested. The m.Mubrane is snmetimrs 111- 
lui-ed i>v patients attempting to remove wax by tlic help of 

• ' _ . . ... .-^K. .1,..,,.. ll.,,,M,lll till' 



U. at pills, eie., w un 11 



,_.,(!,. (l,,!!-! I !\! 



5 
8 ., 



«4 



HASDiiooK oi- i>isi:,isi:s oi- riii: i:ak 



M 



iiu'inl)r;ui('. an accidrnt which has liapiiciicd to surj^n'ons in 
ill-(lirccti(l alt('nij)ts to remove a lureij^n liody without proper 
ilhunination of the nn'atiis. 

Tile internal ear may also l)i' similarly injuri'd l)y the effects 
of concussion, the in(»st frequent causes being loud noises cIosl' 
to the ear. sni h a-> are proihiceil l)y tlu' tirini; of lar;.,'e ordnance 
when tlu' inili\idual is standinj,' near to. and on a le\el with 
or slightly l)e\-on(l and to tin' side of. the month of the ])iecc. 
Fracture of the hase ot the skull, if the fracture jiasses through 
the lal>vrinth. will cause d( atness. hut notwithstanding this, 
loud subjective noises may alterwards ht; a distressing feature 
in the case ; concussion of the brain and severe blows on 
tlie mastoid may cause deatness thnmgh concussion of the 
labvrintli. 

The Patient s Present State. 

The ue.xt steji Ju the examination of the patient consists 
in making a carehd sui\i y ol his preseirt condition. 

The Aspect of the Patient. -From th<> jjaticnt's appearance 
.duable inlormalion is obtained. Should the ])atient be 
young, and ilure is reason (there usually is in atnal j^atients 
at this jieriod (it liie) to suspec t the j)resence of adenoid vege- 
tations, the lacial aspect nnist be noted. There are two 
]ihysiognomies associated witli nasal ojistruction in childri'n. 
in the one there is a sleepy and often vacant look, which, in 
Its most pronoimced type, (k'liotes the so-called aprosexia of 
(iuye. Here the ex])res>ion lacks intelligence, the mouth is 
open. Ihe eyes wide a]>art. the bridge of the nose broad and 
low. with Iretpieutly a vein running transverselv across it ; 
these patients liaxc great dithculty in concentrating the atten- 
tion and maintaining it li.xed on anv siucial sul)ject. In the 
other (lass the no^e is narrow and pinched the ake collapsed, 
and th( mouth open. P.ei\\(en these extremes any niter- 
mediate ' HiditiMii ina\- be met with, \m{ the mouth is always 
op( n al niL;lil. The ])atients. with lew exceptions, snore, 
though the mouth may not be noticeably open during the 
davtmie. '1 he palate i> generally highly arched, often irregu- 
iariy ---<'• aihi ;iu aixiniar .m ii is (.oiiiuu led .irin i"iori\' ; tiu.- 



/■///; (,i:xi:h',u. i:.\,imi\,iti()\ of thi: p.iTn:.\r 25 

Irunt trt'tli projrct outwards, and not uncommonly the interior 
maxilla is. as a \vliol(\ l)adly developed, so that the lower 
incisors come into contact with the posterior surface of the 
upper set. whicli in consecjuence oftt'U assume a more or less 
horizontal direction. Tlie faucial tonsils mav or may not he 
enlari,'e(l ; sliould tlun^ he nasal ohstruction. a ri'sultiu" 
,i:ranular pharynt,Mtis will always \h- ])resent. 

in adults the tendency to mouthdin'athiuf,' should he 
carefully ohserNed. and the state of the patient's lips will 
olteii atford a (hie. as in mouthd)realhers the muco-cutaneous 
sm-tace of the lower lip is dryer than in nosedireathers ; 
patients will often deny that they are mouthd)reathors. when 
it is (]uite evident that (hirinij intervals of speakin;^' their 
hps have !)een obviously apart. As corroborative evidence of 
mouth-breathing in children, besides snoring, there is "-reat 
restlessness during sleej). nif^ht terrors, and comi^laints of 
thirst during the night ; in adults, the i)atient. on waking in 
the morning has often either a dry tongue or a disagreeable 
taste ill the mouth. 

Facial paralysis, if present even to tlie slight(st e.xtt>nt. 
Will l>e easily remarked. Any temlency on the part of the 
patient to look at the month of the examiner should be 
observed ; to detect tliis habit it is a good ])la!i to practise 
speaking with as littU' lip movement as possible. 

Imoiu the iiatieiit's \-oice there is also something to be 
learned. The dead and so-called nasal voice of adenoids 
and ol)struction is easily recognized and never forgotten. 
Neither is the inability which accompanies this condition to 
picuounce distinctly certain letters. .M especially. Patients 
with ihronic iion-suppurative disease of the middle . ar. vwn 
when they are sutteriug from a severe degree of deafness, 
MMially speak in a cpiite low tone, whilst elderly people-, whose 
deaiuess is hugely attributable to old age. not infrequently 
shout. Sulferns bom nerve-dealiiess have in most ( as.'s a 
dull, monotonous delivery. .Malformations of tlie ear, uiicHiual 
pnijrrtions of the auricles, the jiresenc. of new growth, and 
disliguieiiients trom old olh;em.itomata, will be observed, on 
Mipei in lal ixamination. 



■;i 



! 



I t 



26 



haxdhook of Drsr.Asns oi- Tin: /:.i/e 



The Patient's Present History and the Duration of the Disease. 

Tin- Ifiigtli of tinu' that the jtatit-nt lias Mift'cn''! Irom 
Iianlncss ol' iK'aring. tinnitus, or discliarge. should br tare- 
luUy incjuirt'd into, and leadinp; questions will often cause 
liini to consideraMv antedate his orij.,'inal >tatenients. The 
inii)ortance of this histo-y in nou-suppurative <liseases of the 
middle ear lies in the influence it has upon pro,!.;nosis. In 
aiute >up]iurati\-e disease of the ear the jiatient will f,'i\-e a 
niuch nioie correit history than if it is chronic and dates from 
early childhood ; in all suppurative conditions, howcxer. the 
presence of pain, headache, local neuralgias, giddinos. sick- 
ness, nausea, or facial jxiralysis. as well as dellnite cenhral 
symptoms, sue' as loss of memory. es{)eciallv lor nanus and 
l)laces. should i)e most carefully incjuired for. In non- 
sujipurative affections questions should lie directed towards 
the ])resenci> or absence of ailencjids. nasal obstruction, com- 
plaints of (,'iddine>s and jiain. as well as whether or not the 
patients hear their own \-oices better than extraneous sounds, 
and. tnially. whether hearing is better during noise than in 
(juiet. '1 he urine should be examined for albumin or sugar the 
former es])ecially in cases of tinnitus, the latter in acute 
mastoid abscess ; and in elderly ]iatients the condition of the 
bloodvessels is of great import.'uice. 



THE SPECIAL EXAMINATION OF THE PATIENT 

In all cases ot ear trouble, after the patient's history has 
been coni])leted. the ears should lie examint(l before ]iro- 
cei'ding to test the powers of hearing, l^'or should the 
UTcatus be blocked iiy a ct-ruminous plug, aiu' examinatiori 
with the tuning-fork would be useless. 

In the examination of the ear the head-mirrnr should lie 
invariably used. For convenience the ordinar\- i i.iiio-l.irvngo- 
logical mirror with a focus of S inches i> used, but lor liner 
work, .md to olitain a more delinile detailed \iew. ;i mirror 
having a tocus ol about 4^ inches will be found superior. It is 
better, especially in towns, to use artiticial light, but. when 



1 

I 



Tin: GEXERAI. F.XAMIXATIOX OF TIIF IWTIFXT 27 

availalilc. sunlight reflected from a white cloud suiiplics 
s( rviccahle illumination. In order to obtain greater detail 
.1 convex len- ma\- l)e used, either attached to the mirror or 
to the specahim. 

The external ear is rapidly examined with ihe eye, as well 
as with the ling.-r and thund). to detect any thickening or 
.il.normal ccidition of the pinna. The entrance of the meatus. 
its >ize. as well as any ol)\ious obstruction or the existence 
of discharge, must be reviewed. If there is discharge or pain 
comiilaiued of. the surface of the mastoid jirocess shotdd be 
pal])atcd. and at the same time any tendency to redness or 
ptdtincss of the skin in this region looked for." as well as any 
"bhteration of the post-auricular cleft ; the relative projecti(.n 
ul the auricle, as compari'd with its fellow, is an imjiortant 
Mgn. After gentle palpation, firm i)ressure should be matle 
over the whole mastoid process, especially over i\\v site of the 
mastoid antrum— that is to say. a spot close behind the 
am-icle. and at a slightly higher level than the external meatus. 
Ihe elicitation of ])ain here or at any other jMution of the 
mastoid may be considered ])eriosteal in origin if the pressure 
ie(iuired is slight, but due to disease within the bone if the 
pressure required be firm. Again, in i)eriosteal trouble tender- 
ness will be general rather than local. The })resencc also of any 
subcutaneous collection of fluid, of an enlarged gland, or 
<lischarging sinuses in this locality, cannot be missed if this 
scheme of examination be carried out. 

Having now obtained all the information jmssible by tliese 
means, a careful examination is made of the meatus and 
tympanic membrane through a siKMuhim. A form of speculum 
\vhi( h is entirely satisfactory is that of Griiber. It is made 
01 metal, blackened on the hiside. an(' is elliptical in section. 
'1 he specuhim chosen should be the largest which will enter 
the meatus easily, and in cold weather it is better slightly to 
Nvai-m the instrument. In introducing the speculum, the 
pnuia IS taken betwei^n the finger and thumb and drawn 
gently l)ackwar(ls. outwards, and upwards, thus straigiitemng 
••.•.:c .tir.i ; li.tr.nng xn^ i>ii»<i\ei lo oiilaiu tile i)esi 
possible view of its Ulterior and of the tympanic membnme 



f I 

■ \ 
H 

1 

i 
I 

A 

■i 



f •» 



1 



28 



/f.i.\ni!(U)K oi- i)isi:.isi:s of rii:: ear 



Having' ins('rt('<l the sju-culum. the following points aiT to be 
observed : Any obstnietion of the canal whether this be due 
to snbstanees within it. as accnnnilated cerumen, or caused 
1)V a projection of the meatal wall, as by abscess, exostosis, 
or new growth ; whether the obstruction be due to contraction 
of its lunien. either cicatricial or otlierwise. The colour of the 
normal meatus is that of onlinary skin, and any variation 




o 



iS. 



.\eK.\l. MMaei.iM. 



The k'lt-liaiid wdodc ut iriHcsciits tlu- laff^cst-sizi'd Ciriibfr'.s siH'culuin, 
with :i \ irw ol the two cxtri'niit ii's, showinj; tlii'ir ()\-()i(l form. 
'I hf wDddiut (III thi' ri^ht is a Cirulier's spin iiliim nit down to 
enablo the surgeon to oix'ratc more easily on the cinun. 

therefrom should be noted: if it be red from intlammation, 
idcerated. as occasionally hajiiiens in secondary syphilis, or if 
it be uiuL-iUally smootli. uliite. and glist(ning. as in oto- 
sclerosis, or whether its sm'lace exhibits sjiots of a black, siate. 
red. or white tint due to the presence of fungi. Tlie exist'Mice 

not l)e misled. It the lumen of the meatus is not absoluttdy 



77//:' i;i:x/:h',u. j:.\ami.\.iti().\ oi ihf. i'atif.st 



Ik- 



liic from obstruction. i*eps must he taken to render it so. 
wlII as to remove every trace of discliarge or moisture 

■lore jirocee<ling to an examination of the fundus. The 
t\ni])anic membrane is first o])served with tlie patient's head 
trt'ct. and afterwards wi. the head inchned towards the 
opposite shoulder, in order to enable the upjH'r part of the 
drum, together with Slirapnell's nu'ml)rane and tlie meatal 
roof, to coni'" into view. 

It cannot be too firmly impressetl upon students of aural 
surgery that, under no condition whatever, should an ex- 
amination of the tympanic meml^rane be carried out so 
long as there is the slightest trace of moisture within the 
(anal. Indeed, an opinion ought not even to be formed. 
i.util all moisture has Ijccn removed from the ear. though 
>uch cleansing is chiefly necessary in suppurative conditions. 
'I he i)resence of offensive pus would usually justify the 
assumption that the drum was i)erforated ; but it is not 
until the ear has i)een thoroughly cleansed and dried that 
the actual state of the fundus can be accurately determined, 
e\en by the most experienced aurist. 

The inner extremity of the external meatus is normally 
closed by the meinbrana tympani. which is placed with its 
outer surface looking both downwards and outwards ; it is 
this obliquity which enables the skilled examiner to estimate 
any alterations in the general contour of the dnini. In 
soiii' instances the external meatus is so straight. an<l its 
calibre so large, that a fair view of the membrane may be 
olit, lined without the use of the speculum and reflected 
light. In others the meatus v:. so small, and its natural 
cur\es S'^ exaggerated, that only a ]iart ot the neml)rane can 
lie viewed, even by the mo:;t skilled. (F.-r description of the 
membrane, sei' ante.) 

'I he attention shoukl now be directed tow.irds observing 
the colour, transparency, and general clviracteristics of the 
drum ; the direction and aj)parent shape of the handle of the 
mall, us ; the direction, size, shape, and integrity or otherwise 



(it tl 



(/one of Ijiitif. .A It pr.'"!t if^TT nv.d \'P.rint!:in it-i fhi' .-■.-•.t-iii .--.f 

ligli'i i^ one ol the most usual plieromena, and normal hearing 



3" 



iiAxniiooK or disfase.'^ of the far 



iiKiy Ik; (omul wlii'ii the coiif is altiuirruilly sitiuited. more 
(.'S]H'<.i;illv in the vomig. Tlie reason that with the normal 
(hnun the cone does not reaeli to tlie jK-ripliory is on accoimt 
of the change of the curvattn-(- of the mei^hrane. With a 
consi(kTable central depression of the drum the cone shortens, 
liroadens. and often divides in its long axis. With less in- 
drawing til.' changes are of the same character ; but arc less 
niark< (1 widi jiosterior displacement of the malleus. With 
mtation of the hone liackwards the reflex becomes horiz(jntal. 
and conse'iuently shorter, and i^ divitled in many instances. 

Occasionally ;i light reflex is to be noticed behind the 
handle of the ntalleus. and close to the jjostcrior fold of the 
iiiend>raiie. This is of an irregtdar shape, and irregular in 
situation, and it signifies an tmdue laxness oi the posterior 
{■art oi tile tyiujianic nieiiilnane. That is to say. the mem- 
iirane in this sittiation has become stretcluil in its uppier and 
posterior jKirtion:-. that biing the jiart wlu'u- tlu' current of 
air forced up the h.u^t.u hian tul)e impinges most directly on 
the tympanic in.embrane. 

The examiner should also search for jurforations or de- 
pressi(in> in ihe tvmi)anic membrane. A depression t.in 
u>ually 'i" d"te( ted. or dist iiigiiislieii from i pi-rtoration. by 
tile fact that. I'xcept 111 the very snialle.-.t (' liiem. a light 
retiex may lie seen somewhere in its diptlis. causvd liy the 
reflection of light from the indrawn ]u)rtion of the drum, 
whereas in a ]Mrforation one pc\<'r gets a Hgiit letlex unless 
tile jterloratioii be extreiiielv huge, and a small amount of 
light mav lie then rellected from a dry jiromor'ory bared of 
iiiuecus membrane. 

('al( .'.reous jiatelies and ]>atihis of local tlukning. or 
atteiiuatrd ar< as in the drum aKo demand .itteniion. as well 
as any swiriiie,; or inilging ol liie im lulir.ir.e. The latter 
coiidiiioii is !o lie looked for with >pe( ial tare in the ] ostei-ior 
segnn lit , in inthiiiiiii.itorv diseases any Imlging i>i tiie pos- 
terior sujiciior nuatal wall adjacent to the membrane is very 
sigiiilicant ot Mijipuration in the antrum In non-suppuraiivo 
condiiioiw an\ p.uiuular jirommeiice ol the jiosterior fold of 

the niellll>l,ine must |ir liioki d (ol , ill ( Idiilv pt »iple the exi^t- 



77//: C.nXEh'.JL I-XAMIX.iriOX OF THE PATIEXT 



31 



Liicf of a circular peripheral ojiacity resembling the arciis 
^uiilis will frccjuently be observed. When no perforation is 
])resent. .uid deafness is the prominent symjitom. the mobility 
ol the various ])arts of the membrane and of the handle of the 
malleus should be ascertained by the use of Siegle's speculum. 
Indeed, the importance of an intelligent use of the i)neumatic. 
or Siegle's. speculum in all cases of non-suppurative disease 
ol the middle ear cannot l)e overestimated, and is never to 
lie iiinitted. At tlii,-. juTiod of the examination it is well to 
prncicd to investigate tlu nose, naso-i:)harynx. and pharynx, 
wlnl' tlu' |>atient is still in a good position with regard to the 
iiulii. 

Examination of the Nose and Naso-Piiarynx. 

.\i! < xamination of the ear ^^hould in\ariably be accompanied 
by a systematic examination of the nose and naso-pharynx. 
llii imp(jrtancr oi this has long l)ei'n recognized, especially 
ill tlio-c aural diseases incident to childhood, which largely 
dt prnd lor their origin on conditions connected with the 
pn s( lue ot adcnoiil vegrtations in the naso-pharynx. It was 
l(i\n!)ic wiio first descril)ed tiuse growths under the name 
'thiikcu' ' membrane < ausing obstruction of ..e faucial 
"nt'uf ol ,■ Iv.istachian tube.' to which he was in the habit 
<|| .ii>]ilyiiig nitr.ite < ' silver with a curved i)orte-caustiqu >. 
r>' sid( s tins abnormal .state there are m::nerous morbid con- 
'liiiiiib. in tbe nose and naso-jiharynx which are responsible 
l"|- s( (ondary pathological ])r'.»cesses in the I'ar ; unfortunately, 
in .1 large majority of cases treatment directed to the removal 
• '1 t(irre(tion of abnormal conditions in the nose and naso- 
lili.iryn.\ will not be attended with any marked im])rovement 
111 l!ir h( .11 iiig jKiwer on account of the duration of the aural 
'iiiplaiut. wliieh has resulted in permanent injury of the ear 
■'"'''■ I li'^ taiiure is apart, howi'ver. from any comfort 

■ 1" ruui^' to the jiatiint from caridul attention to the nasal 
'ii'ulile; nevertheless, by local treatment of this kind it is 
|'"-s||,|,. to lei.ard the {irogrcss of tlie disease in f ear. Fiom 

■ I pathological standpoint it is j)ossible to (.1 .n from the 
iias.d ((.nditioii valuable mformaticm which may assist in 



' li 1 einiin nil' t\\,- 



1 11 1 1 T I I 1 



.1 . 



,.,.,1., 



I 



I 



32 



HAXDnOOK OF DIS EASES OF THE EAR 



The oxamination in question consists in iiie inspection of 
the nasal elianibers from the front, a procedure known as 
anterior rhinoscojiy ; from hehiml. the naso-pharynx and 
jiosterior choan;e may l)e indirectly viewed, a method known 
as Jiosterior rhinosiopv. In order to insjiect the nose from 
the front, reflectt'd liL;ht is diri'cted by means of a fori'head 
mirror into the anterior nans, tlie al;e of which are held ajiart 
liy means of one of the various forms of nasal >i)ecula. Thudi- 
chtim's licinf,' one of the most convenient. At the comnie.ice- 
ment of tlu' examination the head shouM he ki^pt jievfectly 
uprif;ht. tlie tip of the nose hein^' ekvated Iiy the examiner. 
In this i)osture the lower part of the se]itum and the front 
portion of tln' inferior turliinate body can be examined. 
Theoretically, the septum sliould l)e perfi'ctly uprij^ht as well 
as strai{;ht antero-posteriorly. and the inferior turoinate 




FK.. ii).- iiienKiirM's n.vsal spi-crLCM. 

body should be separateil from it by an a])pre( iable distance. 
on an averaj^e ,',, inch. I In' lower idf;e df tlie inii rior tiu^- 
binate sliould alsd lie separated fiom tlie tloor of tlic nose i)y 
an interxal of aliout ,',. to ! inch for its whole length. The 
sept.il niMions nuinliraue has a yellowish ]>ink hue. whilst 
tiiat ol the infirior turbinate i> ])ink in 1 olinn'. 

The abnormal (unditinns freciuently inund in th- nose are 
irre);ulantn s in the direction of the ->eiit>im as detleitions 
from the lurptiKlicular plane and lo( ali/.id ]Mdje( tions. tlie 
latter lieiuf.^ coniniiiiily know 11 .i> i rests or sjiui^, I lu' .limorm.d 
states of tlie turlnnate are usually e\ idem cd eitlier by an 
inciease itr diminution in si/.e. The inue.ise in si/e of an 
inferior turi'inate is f^'reatest when the -.e|itum is defk'cted 
towards the opposite ca\ity ; in these cases the bone, as well 
as Its miu ous ( menni; will olleu lie li\ pt rtropliied ; tiie 



1 



////:■ C. i:\-EUAL JLX.IMIXATIOX Ol- Till: P lTIi:xr 3.5 

• iiniinulion in size is most inarkcil in advancrd c.isrs of tlir 
<lis(asc known as atn)])hic rhinitis— in fact, the hone ni.iy la- 
coniplttily al)S()rl)ecl with tlu> exception of the sujierior jtart 
ol the anterior extremity. The nasal cavity then a])pears 
wry large and roomy, and is usually filled with offensive 
eni>ts. tile Removal of which frequently enables the examiner 
to ol.Mi-vc the orilice of the Eustachian tuhe and tiie superior 
<(li;i' ol ihe posterior choana. 

From the ].oint of view of the aurist. the most imjiortant 
ih\iHons ()i the nose are tiie inferior and middle m(>atus. for 
it I-- in any interlirence wuli the current of air normally 
directed into the mouth of the Eustachian tube, as well as 
in certain jiathological chauf^-es in the mucous membrane- 
tor example, rhinitis sicca, more noticeable on the inferior 
turbinate body than elsewhere- that his jtrincipal interest lies. 
Posterior rhinoscopy consists in the examination of the 
uaso-pliarynx l>y means of a mirror. The i)atient slit,'htly 
llirow^ back t!ie head the mouth is opened, and tlie toiii^nie 
.Urutly i)ut lirmly depressed iiy means of a tongue depressor, 
the most generally serviceable pattern beiuf,^ the old-fashioned 
our with a lilade of larj^'e size, as it causes less irritation, and 
kicjis down Ihe t'ntire tongu" !)etter than the snudler ]iattorns. 
.\ small mirror— either one worked with a hinge, so that it 
can be elevated or depressed at pleasure (Michel's), or a 
-mall-sized laryngeal mirror, with the mirror bent at a right 
ingle to tne sh.dt -is passed gently I>ackwards (.ver the base 
ol the tongue, care being taken not to toudi the })osterior 
pharyngeal wall, .and it is possible to obser\i' the oflrction, 
part by jKirt . of the whole of the naso-pharvngeal cavity. 
IliN procedure recjuins coiist.int practice if valuable ( linical 
data an to be obtained, and no oi)portmiity shotdd be 
ii'gl.d.d of actiuiring and maintaining the necessary dex- 
1' rity. It is necessary that a soft jialate be relaxed in order 
that .1 good view o! the p.uts above and behind mav be 
ola. lined ; this relaxafon is obtain. mI by directing thr patient 
'o breathe through the nose without dosing the mouth. 
l'"-terior rhinoscopy will be a.ssisted by spraying the fauces 
1" those iialienl.s \\ilh irritdile thro.its with .x sni.!!! ouaiititv 



34 iiAxunooK or diseases ue the ear 

of a 3 per cent, solution of cocaine ; and a relaxed and jiassive 
condition of ihi" palate may bo occasionally ol)tained l)y 
placing the palm of the hand over the patient's open mouth, 
and directing him to res])ire through the nose. Before the 
presence of abnormal conditions can l)e <liagnosed. a know- 
ledge of the normal anatcmiical appearance is necessary. The 
vault of the healthy pharynx is of a i)ale i)ink colom-. and 
should exl( iid consideral)ly above the lornices of the choan;e. 
The oriliees uf the Eustachian tubes, with their projecting 




FIG. 20.— r>IAr,R.\MM.XTIC SKFTCH OF rOSTFKIOH N.^RFS. RIGHT SIDE 
IN DIAGRAM IS NORMAL. 

I Inferior tiubinate IkmU. posterior (-xtrcmils ; .:. pharyn^;eal cx- 

' tr.-nutv of the Kustachian tube ; 3, mi(l>lU turbinate, p.strnor 

fxlr.mitv 4. adenoul mass, showing how the lornix of the pos- 

tciioi nares 1- liuUUn wlun this urovvth is iirisMU ; 3. enlarKenu-nt 

of tlic iiostrnor rxtrenulN of tlie inferior turlnnate bodv 

lips, should not extend suitinentlv mto the , avity to o!)s1ruct 
at all the view ol the lower ].art (d the . lio.inie. 1 lie po>tenor 
free .'dge of the Mjituni t iruied by the vomer is straight and 
thin; and on each sid. . projecting into e.uli . lioana from 
withoul inwards and dow..,\ards. are se. n norni.dlv two pale 
pink uncitorni processes, the i>' nio, 1 \<nniili' ^ ot the 
inferior an.l middle tnrbinal.- l.odies. while in a nlafively 
small proportion of cases mav be ob; e v.'d m tlu' npi"'' I'^^rt 
of the ihoan.e the free e.lges d ilie superior turl aial \»^^w•^. 
'llie more Irecineiit almorm.d c uMiiiions mei xMili (unsisi m 



Tin: (,i-XEiiAL /:x.iMix rriox 



or Tin: i\iTii:xT 



n iiiiilui' (levelcpmcnt of lymphoid ti: 



tlu' n;iso-j)]iar\nx. 'J"Ili^ 



vi\L;ctali!/n (F 



till' cliamlxr is iowm 



^slu■s al)out the roof of 
o\-,igroutIi i^ known as adenoid 
cases the roof 



7) ; iind in w ( ll-niarked 



so iniuii that tlie f 



ornici's and npjHT 



i.irt of the na^al s.-i)tuni arc invisil)!. and the roof, histead 



^ipjH'.iriiif; as a lii"h \ 



oi 



il th( 



^]ia(■ 



■twcen tlie J' 



lult. IS eonvtx and nif^ose. the \vhol( 



111 



liypertmiihie mass, i 



ustachian lubes iieinj,' occujiicd hy 
examples it hecomes 



11 less sewre 



oss;e 01 Kosenii 



us sit 



lull 



er are 



e e\-en a 



most imjiortant to note wlielher the f 

Ine or (Meupi. d liy lymphoid tissue, sinee in tl 

Miiall .imoiint (,f morbid (.growth will prevent free ingress of 

■ iir into the JuiMaeliian tube, by interfering,' with ihe move- 

lllel" (,t Its Iree 



posterior lip. and also by the ext 



ens ion 



ot 1 ammatMiy eatarrhal changes from the adenoid ^lowtl 



til the ost ium 



Tl 



K're 



are numerous instni mental devices for lioli 



lin.i,' llu 



soft jalate forwards in order to obtain a ^-tter view ol the 
na>o-phaiyiix m those patients who are unable to exercise 
sufficient self-eontrol to keep the soft palate depen.Knt and 
passive. By the aid of a Httle cocaine and the exercise of 
I atience. however, the use ot such instruments .and methods, 
uliiih are extn'inely unpleasant to the patient are in most 
ea.ses avoided, and thiy ought not to be resorted to unless 
It IS otherwise impossii>le to obtain the neces.sary information ; 
nor should the practuc of introducing the hnger into the 
n.iso-i.harynx toconrirm the presence of adenoids be adopted 
a> a routine measure. It is not UMially necessary to .lo so 
|\eii ill .juite young children, for the u.se of a '])ost-nasal 
■ iiinor 1^ usually possible; and the introduction of a linger 
into the naso-pharyux tngliti iis and, if roughly performed, 
iiurt^ 111, ejiild rendering subseciueiit Ireatment' less easy (,11 
a<couiit (.1 the terror and distrust of the little pa;i,nt. ^'ri-,,. 
lollowing lai ts wll in the gnat majorilv of cases determine the 
pii V iKe of .tdenoid veg.'tations m the naso-pharynx without 
aiiyHi.il mvcstigation: A subject ol adenoid vegetal ions .snores 
at ii.,;ht. ami is ,1 moutlidireatlier. with .Iry lips, usu.dly has a 
high palate and there will always be gramdes present" in the 
■■ |iiiai\ii.\, i iicse signs. I oinliuii d with either the presence 



£-10 



3«, ii.ixDiiooK Oh i)!si:.isi:s oi- nu: i:ah 

of or llic his1(.rv of diMliarj^^r from the i ;ir or ibafncss. or tho 
I'Nisteiii (• of an alteration in th'' dircrtioii and intrf;rity of the 
cone of li-lit on till' tympanic nuinhranc. arc sufficient indica- 
tions ol na-o-pliaryiiLjcal obstruction of tliis kind. (For t!ic 
facial ai'iicarancfs in tlic^c c ascs. sec a)Jtc. y. -'4.) 

AnotlKr freciu.iit and extremely iini)ortaiit deviation from 
tlie normal is an enlarf^eincnt of the jiostcrior ends of the 
interior tnrl.inalo (Fif; -'o ^i). which hecomc round mas>es, 
I'lllin.L;- uj. sometimes the lower part of th.' (hoanrv. and i>ro- 
jeclint: Ikk Inwards lor a cousideralile extent into the naso- 
jiharynx. 'llie a-ppearatice nf thest- swellings varies much 
both in colour and si/.e. They may look like nnilherrie^. dark 
in colour, with a nodular surface; sometimes they arc large 
masses, Miiooth and red ; at other times white and glistening, 
reseml'ling ;i na>al iiolvpus. Similar changes to the last are 
noticed, hut less fre(|uently. in conned ion with the middle 
turhin.ite. Other nasal conditions, such as the presence of 
polypi, adherent cru^t--. or an air(»phied state of the imicous 
membrane, though freiiuently observed, have, with the I'xccp- 
tion nf atrophy, little direc t bearing on aural disease ; l)Ut 
they should alwavs be noted, uith the view of treatment upon 
general i)rinciples. 

As part of this examination, the size of the faucial tonsils, 
and the colour of the mucous membrane of the jiosterior wall 
of til' ]iharynx, ai\' to be obsirved, enlargement of tlie lau( ial 
tonsil> 111 (hildreii being rarely unaccompanied by enlargement 
of the i.o^t-nasal lymphoid tisMie. It is rare that ablation of 
the i;uu i.d tonsils alone will be ol any assistance in correcting 
the aural trouble, '[he pharyngeal wall should be inspected 
f(,|- the presence of the scattered and enlarged collections of 
lynijihoid li>sne surrounding the mucous glands of the jiart. 
luaniiested by small elevations, jiale and glistening when there 
is no active , atarrhal state present but otherwise bright red. 
This condition is known as ■granular jiharyngitis.' Inllain- 
niation ol tlii> kind and in this situation, whethtr acub- or 
(hionic. i^ path(igiioinoni( ol a post-nasal c;itarrli. the irri- 
tating nnuus tlcwin;; nv( r the pharynx 1 anting tlie lymphoid 
tissue Willi ii -~urre'mii-> tiie jiliai yngi ai mu. mir. i,ian>is 10 
liccomc swul 11 



art . 



WW 



ain- 



■ or 
ini- 



l .-> irf 



CllAPTKR III 

SPECIAL SYMPTOMS AND THEIR IMPORT 

Deafness. — Thr n'lati\c amount of dcalHiss. from ^Yv^ht 
'luln.ss of hcarin.t; to absolute deafness, reciuires eareful eon- 
>!deration. with its ons.'t. duration, and ai)])ar(nt causation 

Otalgia, or Pain in the Ear. -Pain is pnsent in all arntt' in- 
llammatory <lisorders. espreially if tmdin^' towards or aerom- 
panied by suppuration, wluther it be in the middle ear or 
r.xtcrnal meatus. In aeute ee/A'ina of the car the ])ain is of 
a burning eharaeter. but not wry aeute. In furuneulosis of 
tile meatus it is sevcrr. lancinating. stabi)ing. or throlibuig in 
liiaracter, and usually i)r(Vents the suff.rer from obtaining 
>lerp for several nights. Pain is present in the most mark.-.l 
'li'grce in acute nitlammation of the middle ear. In infants 
It will be detected by the child crying wheuewr the ear is 
touched or washed, or by th.> frcjuent pla< ing of the hand over 
111'' <ar and rolling of the hea.l about on the pillow. These 
M,i;ns may be a( companied, when the intlaiumation is s.non 
d.u-y to a broiu i,o-pnrumonia. iiy retraction ol tlie head. In 
idults. pain in acute otitis media suppurativa i> olten most 
'Airuciating. and. though worse, resembles m char.K ter a 



severe toothacht 



hat 



tior 



\\ Inch ac ((impaiiK 



a( iit 



e e\ai rr 



> ot ( liromc suppuration in the mi<ldle car is It 



■-lAere 



.mil 



lo<al 



i/cd. When dn. 



tl 



le 



'pu rat ion in the temporal bone or I o an absc( 



|ireselice of a liu lis o| 



betW 



nav lie \( 



se\-er( 



-•kull and the dura mater it i 
'I'lite lo( alizeil. Is olten more neuialgi( in charai t 
t tile head and <lown the nei k, P, 



erll t he 



'■\ er till 



-Hie o 



-ideoi the head, aiid .xtendmg.lown tl 



rr. radiating 
tin over the 



^KUU on pell Usslon 



ic Ile( k. Wll h It'Ilderiles- 
'V pain m llie oi ( i|iiit , ^houM diivi t 
J7 



38 



HANDBOOK OF DISEASES OF THE EAR 



attention to the possilnlity of intracranial mischief. Pain 
is l)y no means an nnnsual symptom in chronic non-snp- 
j)urative middle-ear disease. Mere it is neither severe nor 
constant, and is inert' of an aching cliaracter. By far the most 
serious form of otalgia is one whicli oceasionallv accomi)anies 
middle or internal ear dist^ase, and is of a neuralgic character, 
almost unl)earai>le in its inti'nsity. Referred pain in or alnnit 
the ear from diseases in niighhouring regions is occasionally 
met with. Dental caries is a fruitful source of otalgia, nu)n- 
frcciuently when the dist-ase is in tlu' upper jaw. In all cases 
in which no other cause is found, the most minute attention 
should hi' directed to the teeth, for fre(iutntlv the offending 
tooth is apjiarently (juiescent. and may ln' satisfat torily 
stoppt'd. Jispecially tn hv nnted in tins connectiim are 
malignant disease of the pharyn.v and larynx and u])i)er 
jKirt of the (esophagus, (juinsy. and p;'in is said to he ilue 
occasionally to nasal olistruction. Pain or tentlerni'ss on i)al- 
pation ovt-r the uuistoid will always lead to a su>i>icion of 
inifammatory disease in the mastoid; and ahow and iMhind 
the ear, oi' se\t're frontal cejihalalgia with discliarge from 
the ear. to intracranial suppuration. 

Ulceration of the ]iharyngeal e.xtrrmitv of tlu ICustaihian 
tulx' may also gi\f ri^e to ear ]>ain. 

Patients ol middle age ami upwards occasionally comjilain 
ot severe iKiin in the ear. and when upon a careful i>\aminat ion 
uitthmg can he foimd in or around tiic car arising from any 
ol the aforenuntioned causes to account in an\ way for tlu' 
j)ain. deafness iuing usiudly al)sent. the tem]ioro-maxo- 
articulation should lie c.irefully examined as it nuiy fre(]uintl\ 
he the seat of an arthritis, the clo>e ]>roxiiiiity of the joint 
t(i tile ( ar leading the patient to rvivr the (laiu to that jiart . 

Discharge. 1 he ( harat ter. cdusistency. quantity, and ( niour 
ol tile distli.irge sliduld he carelully iiu'estigated. It ni.iy he 
oitensive or mlourles^, purie Mt . \\ater\-. i>v sanidus ; il puru- 
liiit. It may i)e thin or rop\ Discharge is jire^eut m the 
lollouing diseases : 

lu'iiiui I'! the E\tcr)hi! Mi(ilii\. Tie discharge is either 
w.iterv or gummy m iliaractir. It ;.> r.ireK iimuhnt. .md 



SPECIAL SYMPTOMS AND THEIR IMPORT 39 

when so. occurs in cases of long duration, when it will have 
a faint offensive odour, due to the presence of decomposing 
epithelium. 

Otomycosis as a cause of eczema is equally a cause of 
discharge, as is at times in cenimen. 

rnrunculosis of the Meal us. —W-ry severe pain always pre- 
cedes the discliarge in tliese cases. The latter is thick, scanty, 
and purulent, and can he detected coming from a solitary sjiot 
in tlie outer part of the meatal wall, and not througti a i)er- 
toration m the memlirane or through a sinus in the tlee})est 
jiarts of the meatus. 

Otitis Media Suppurativa Acuta.— l\\c discharge is occa- 
sionally watery or sanious at the commencement, hut gradually 
after a tune heconies ])urulent. and may he roi)y inconsistency. 

Otitis Media Suppurativa Chronica.— Thv discharge here 
may vary from an almost imperceptihle moisture within the 
canal or a slight staining of the i)il!ow-case at night to a 
jirofuse and contmuous discharge. It may he nu)st hetid, 
or. on the contrary, odom-less ; usually purulent. Imt at times 
almost watery. It is occasionally tinged with l)l()od from the 
presence of polyj)! or granulations, or at other times the 
presence of small flakes of carious l)one will have lieen noticed 
hy the patient, in which case it is sometimes said to have an 
ndour peculiar to diseased hone ; or will show small ffakes 
of e.xloliatetl epithelium of cholesteatomatous origin. 

Otitis Media Ilcenuirrhai^ica. — This disease, winch most 
Irecpiently follows inthienza. though not invariably, is char- 
acterized hy the discharge of blood from the t'xternal meatus, 
lliis bleeding may \)c coutiuid to a single discharge, or may 
he rej)ealcd. 

Fracture oj the Base oj the Sku/l.- Shoukl the fracture have 
l>asM(l through the tempinal Ix.ne, l)lood will How from the 
I ar. and is sometimes followed by a more or less copious escape 
of watery discharge of low spe( ific gravity— the cerebro- 
spinal lluid. 

Malignant Disea'te of the Middle liar or Meatus. --Uiu dis- 
< liarge is scanty, oiien \ery offensive, and sanious, 

vcrii^v. — iT i.- j>ci'najj& iutuii^ incc^haiy to remark liiat 



I 



i-i I 



1^ 






u 



40 



HAXDEOOK OF DISEASES OF THE EAR 



V(rti,t;(, i^ l,y no incaii^ iiccissarily of aural orij^'in. Imt I'.iat it 
may .'irisc Ironi nuuirrou^ other iiio:i.i<l slates of tlic system. 
Aural \-erti,L,'o may he divided into two ili>tinet (lasses — 
^vin-fal viTtiL;o and sj-),.(ili( vertit^'o. 

P>y a general \-erti,i,'o is tiiidei->too(l that variety in which 

there r- no speeilie teiideiiry for the jiatieiit to fall, nor for 

ohjeets to rexoKe, in a particular direction. It is a symi)tom 

111 chronic iion-.vipinnative di-ease of the middle ear. esiHcially 

'" 'i''^' "' 'lie scleroli. t\)ie. 'Hie at t a(d<s are sudden in 

<iri.i;in and \ary much in se\-erii\-. from a transiiiU .giddiness 

to an almost comjilete h.^s of ((.n-^ciousness, cansiu,i; the 

jiatient to lall to the ground. It i- . ,, ]>n sent in all instances 

in \\hi( h theri- i^, undue ]ires-~ine within lh.' hdiyrinth. such as 

occin-s, !,„■ example, occasionally in ,L;ont\- people and in tlie 

hiemorrha.t^ic ( ifnsions of leucocytluumia. It may also he 

caused at times l>y syrin,L;im,' when the ilrum is intact, and a 

hircihl. jet ol water is sent din < tly a;.;ainst the l\nipanic mein- 

hrane. {•;>pi ( jaily when the menU)rane is perforated, the use 

ol too (did or too Imi lotions may cause \'erti,i;o. It i^, for this 

re.ison that a jiatient should always he seated while his ears 

are hein^t.' syrin/^ed. With the exercise of e\-erv caie. there 

are some individuals uith sound ears who com])l.nn of i.;iddi- 

ness whenever their ear.-^ are >yrin,L;ed. 

Sjieciru aur.il \erti^;o is due to iiri'ation of one or other ol 
the semicircul.ii cjinaU. in < oje ,;i listiiK tion to .L^eueral \-erti,i;(i. 
which is due to a ,i;eneral c arhance of the lahyrinth or to 
some l..r(( ai tiu.t; directly or indindlv on the feiiestr.i o\-alis. 
Spccilic \-erliL;o has t haraclerist ics jieculiar to the seini- 
circnl.u- canal affeded. If this is. as is most fre(]U( lUlv the 
case, the (Menial Semicircular canal, ohjeets lia\-e a tendency 
to rotate in a horizontal plane fioin the affected towar.ls the 
^'""I'l '-i'lc. ll ii is the sup( rior canal, ohjeets rotati' in a 
''■'■II" 'il plane, and llie jMlieut tends to fall foi'wards ; and 
^^ "1' the p(,si, ridi . hackwards. Speeilie \'erti;.;o is occasionally 
noticed when s\rin,^in,i; the e.ir in chronic suppurative disease 
or alt( 1 the perlorm.uuc of ihe radical mastoid operation. In 
these ( Mses jt Is due to erosion of the houy seuiicircul.ir camd. 
wiiiie in mll.imm.itoiA ci^idit ions (,| 1 hr lemjior.il hone c,ui>ed 



SPECIAL SYMPTOMS IXD THEIR IMPORT 



h\- tho same discas 



liis viTtipo inav 



(.Uf to osteitis e!' the siirri ndin'' I 



spontaneous, and is 



lie aeeoinpanied hy a hit( 



one. In l)otli cases it will 



Se\-ere ^enefal vert it; , is u fn 



nvstaf.;inus. 



matoi-y disease of tlir lal)viinth 



■queiit symjitoin in inflam- 



It 



and .ihscrss of t]n> eere])ellnin 



may 



'e e uiseil m raie i'i-.tanees l.y a 



or in\-o]vint,r the anditor\- n 



ninotir pressini,^ njion 



abo tile ( 
th 



hief 



s\niptoin m Menien^'s d 



ervi' witliin tlir skull. \'ertipo i> 



isease and in elfusion 



within the lahyrinth (see | j^ i ,•/ v,-.,.). 

Tinnitus, or Noises in the Ear, iii'a\ he divided into sid)- 
i'Ttiv or iioi-..s ivIeiT. d I , tl hrad and ikmm-s ivferred to 
llu' ear and ohjretiN-r mds heard hy -tht'is as wall a- hy 
the patient. 

Xoisi-s rcjcyycd lo the llt\,d aiv Jthi i due to aural disease, 
"r thry may h>\^ a eeivhral ..ri-in. In tlu. f,,rnier instance 
they haw a hissm- (,r sint^un., eharact. r. are hiirl\- constant 
and uniform ,:i lutmsity. and ..ftcn of loni,' duration. When 
"' '''TelM-al ori-in, they (htui ,is an early sji^ui „f mmtal 
'1' ran ., ni.nt. and f.T ujually take tie- eharaeter nf voie.s ; and 
when tmii.ns of aural origin e(unmeners to assuiue such a 
' '''"''^' \""' ' '-^ -'111 indication h.r caivlul imiuiry into the 
jiatieni - luciitai condition. 

.Ve/,sv.s n-,T;v'/ /" tnr Ear.- Thes,. may b,e j.resent in hotli 
suiipnrativi' and uon-suppurative disivase of the nnddle ear. 
'I hey are more anienahle to treat m.iit than the ion -oin-, and 
are not infreciucntly consid.rahly militated h\ ir na^al 
treatment. 'Ihere are two chief varieties of >ul.jective 
soimds-a ])iu>at()ry one. synchronous with the heart's heat. 
and ih\r t,, ;i„ iihnormal traiismiN>ion of the souu<ls of the 
licart ; and tinnitus proper, due to a distinct int ralahyriuthine 
'ause. These latter sounds are de.s, rih, d hy the patients as 
l^<in,i; of a hi^>in-. whistling char.u ter. at times lik.'ned to the 
'i"i>e ol a l.oiliiig kettk'. whilst occa -mally hissing or lon<l 



i.s sounds .ire 



nuisical notes are comjilained ot, '1 !,,■ sm. 
the most con>tant, though the louder noi>es aiv perh.ips th- 
iiiore annoying. -]')„. pulsa- .ry sotmd is, as has been .-aid. 
due to some ahnonii.d cnnilit 1..11 ,.itl>,..- ,.( .1... „~_. 1 ;„...,.. ^.,1, . 
^y>tciii or to some fault of hone-(()nductioii. which c.,,i>es the 



I 



m 



^\ 



4a 



HANDBOOK OF DISEASES OF THE EAR 



sound of the heart's beat, usually inaudilile. to l)e heard by 
tlu' })atient. That this is Ircqui'iitly due to some trouble 
in the vascular system may l)e deihiced from the fact that 
drugs, ^ueh as iligitalis. whicli act ilinn-tly on the heart and 
bI()od\issL'l>, arc vcrv u^chil in controlhni^ the unpleasant 
symptom. 'J'lie hi>sing or singing tinnitus is always more 
eom])lained of at night or on ri>ing in the morning — a fact 
which is ])artiallv due to the relative absence of extraneous 
soimds at these times, or it mav he to tiie change of position. 
Ranly a clicking noise due to spasiriodic contractions of the 
sta|iedius nniscle is complained ot. 

Whilst tinnitus rarely jirevents sleeji, sufferers from this 
trouble frecjueiuly experience cim^ideralile difficulty in 
getting to slee]). In ntnirotic ]iatients it may l)e<-ome so dis- 
tressing and intolerable as to Kuid tlniu to commit suicide. 
When tinnitus is complained of. and seems c^ut of proportion 
to the aural diM-ase. tlu' MihkI [)l■l■^^ure shc-uM be taken and 
tile tu'ine shoulil be examined for albumin — a clinical rule 
\V!irthv of extension to all the^^t' cases. 

Objective Tinnitus, or noises audible to others also, are either 
due to a more or less voluntary contraction of the tensors 
tynapani or palati, or the heart-sounds may be heard by the 
auscultatory tube. The nmscular contracticnis are often 
audible without the aid of the tube. 

Symptoms caused by Drugs.— Certain drugs cause both 
deatness ami tiimitus. particularly quinine, the salicylates, 
and antii)vrin. The (U'afness caused i)v these drugs usually 
passes away more r.ti)idly than does the tinnitus, .\lthough 
the administration of tiiese drugs in jiatients wiih normal 
ears will cause no jiermanent ill-effects, it is well, in patients 
suffering from (lironic non-sup})urative diseases of the ear, 
to exercise great Care and circumspi'Ction in prescribing these 
reUiedies. as. accoriling to Friidreich, there is a jiossil)ility of 
causing an etfnsiun into the labyrhuh, an accident which 
woidd interisity th'- aural trouble. 

facial Paralysis is otten seen in cases of slight and transitory 
mi'ldle-ear nitiaiiimat ion, in acute sui)pur.itioii. and in chronic 
suppurati(;n. 



SPECIAL SYMPTOMS AND THEIR IMPORT 43 

Paralysis of the Sixth Nerve is seen as an occasional 
symptom in labyrinthine suppuration, in the mastoiditis of 
childron. and in meningitis and cercl)ellar abscess. 

Tausea and Vomiting. These are symptoms which present 
themselves in increase el intralaoyrinthine ])ressure. such as 
ocean, in intlammation of th.e semicircular -anal and in 
-Meniere's symptom^. 1 luy ai. also occasu..... accompani- 
'lenls v.; the ■'■ertigo which may o( ( iir durin-,' the progn>ss of 
iion-NUiipuratix-e disease 01 the middle ear. Vomiting may 
i)e jm'Sent in all form- of aural suj)purativ disease in whicii 
septic absorjition has occurred, and is a jiromiut'Ut symptom 
in intracranial complications. Wlien the \-omhing occurs 
with cerebral or cerebellar abscess its onset is sudden, and 
without connection with the ingestion of food. 

Rigors.— Rigors, liowever slight, are of great importance, 
and are found in a great number of septic processes due to 
middle-ear suppuration. They are most severe, and accom- 
panied by the highest temjieratu'-es in septic infection of the 
lateral sinus, and in such cases are usually repeated ; they 
are present, though in a less marked degree, in septic menin- 
gitis and in acute cerebral infection. 

Nystagmus.— N'ystagnuis is met with as a symptom in 
mastoid disease, in affections of the semicircular canals, and 
in cerebellar abscess or meningitis. 

Paracusis Willisil.— By this term is understood that symp- 
tom of aural disease in which the patients hear better in a 
noise or when travelling in a noisy vehicle. 

Autophonia is a term used to convey the information that 
the patient hears liis own voice vi-ry loudly, whik he is more 
or less deaf to extraneous sounds. 

Delay-d Hearing.— Delayed hearing ri'sults partly from a 
want of attention on the part of the patient whose sense of 
hearing is gradmdly becoming los and less acute, and partly 
on account of the troubl(> which is necessary in d.caf people, 
or t hose slightly hard of hearing, of always being on the qui vivc 
to aeoid missing the introductory words of a sentence or 
remark. One sees tliis !>avt irnl.'.rlv in r!!!!:lri'!i ■.•.•!■..-■. ■-■-.•.^ 
" What ?" and if no reply is given often by their next remark 



iiii 



It 



»<ti 






'3 a 

m 



44 



lIAXnilOOK ( 



-,r D/5/:.!S/rs of the ear 



lic.uin^'. is u>\uilly a >;, .Hi)t()in of 



pvov. that tlu.y really heard what was saul. It is possible 
llKLt part ol ,his .U.lav.cl hoaring is a graJvial loss of automatic 
^^,,,,„^ ,„,„,,,„ thr uuditory and allu.l c..vl.ral cmtrrs. tha 
,h,. .irkcNvl h-arnu; .> in vc-.Uty ^U.f^^^i^h perception ancl 
^^,,,,,,,,,,,i„„. Tl:,> drl.tv often i> so marked as t<. oe e.oable 

(il lifiuL,' liinrd. 

Hyperacusis, or p.nninl 
(cntr.d or n.inastlimie oii^m. 

Diplacusis .> a , un.lit.on m ulucli llu- .ar^ luar a t;iv. n note 
at (liltiiiiit pitelh -.. 

Diabetes and Glycosuria. W li-n one n ,di/,. s how irequently 
,l„.s.. enn,Ut,o„. neenraft.T nuddle a,^. . it l,eeonK. ohvums 
,1,„ ,lu..,.pat.rnt.-oun„tothrirlow.rrd vHalnv- must l.e 
vatlur mniv pmn. to arntr uiilammations of all sorts than 
,^,,,,1,, „„,„ |„.ahhv.nrml>ers,:{thHunnanrare. It theretoie 
l,,hov. . us to eons.d.r t h. l-avu.- ol 1 hat ui... ^eurral .hetnm 
._it poss.hlr to av.nd 111. kuhr m .Uahrtie or t^lycoMinc 
p,„,ms. 'Ihu.. oura.t.MHpl.a, .un.m.be.arh,r>ta^..so 
'.,„.. nulls n>,d>a >houM 1.,. nuMv vigorous and deu-rnun.d. It 

pnsMl.K^ thar, usu d. 15ut il oprralion has to he prriormeM. u 
L Muallv nupor.anl . ha. . h. oprra, .on sl.ould h.. done Wit l.out 
„,„1.M. loss ,,l . n,.r, so as to loeal/,. . i.' d,s,.a>. and iv.vKr the 

„,„,nn as s,n,pi'' ■'-- l-"''''''' ''"' wl:a..v,r uv .nav do. 
an aeul.- o.,.,s nu,!.a o,,u,rne; ,n a duh,.,,- or ^Iveosur.c 
suhi'i I i- ■' ' '"-' '"' ^'■■'^'' ai.Mi t\. 



INDICATIONS FOR INTRANASAL TREATMENT 

v,.,n.u.i....dp,inMpl.sn,us. 1„ lai.MuunIo, .iu.KU.dan.e 
,,| ,1,. piaMinunr, ,11 drndinu vvhnhu u, nm s,H.ual ..vat- 
n„nl shnuld 1- dH.,-,d to ihr ..OS, aud nasn-pl,arv..x m 
cases ,.| .l.al.Mss ,uel auial disea.->e K-nnallv. W.H- "■Ka.d 
,,, ,l„, pivsruee .-! ad. nmd vrt,'e1a1 'ons. lh. n ivni..val .. 
,„a.tuallvinva,-,ahlv.n..s.a,Ah.. ,ha' . ,nv .,1 dw, lia.p' l.->n 
the ini.Mle far Ml . h.l.li..!. and sh.Hd.lh.. ,..•.... M'tlv un.l. I. aK... 

lu.v.-.V >...!. case all.. . h.-nhs,.!. n. . ..lalla.ul. svinptmas. 
l.nli, .unal and nasal. 1 h. pi.s...,. nl ad,. ,....! v.^.taUons 
.-;i„„ot he Innkr.l upoi, a^ ha. ml- s^ ul>' n 'h- r. .> ih, shelit. st 



IXDICATIOSS low IMl^'.lX.lS.lL I Ui.A IM i:.\T 



-15 






(li\ifnoss dctoctcd. or wlun tlu-rc is the Ifiist dtviutioii iiDiu 
the iKirmal i'^. the curvature of the mcnihraua tynipani. as 
sliown 1)^ '. appeaiauce ami situation of tlie cone of Uj^hl. 
Al>o. it 'le allowed that tlu' i>resence of thest' f^Towths 

renders t currence of aural complications more likely in 

all cases o. asal catarrh ; they are. 'urther. a distinct com]ili- 
cation in tiie exanthemata and in other fehrile disorders. 
The (juestion of tlu' n^moval of adenoid \-ej.;etations in all cases 
where they are found is one on which there exi>ts some diver- 
sity of oj>inion. Viewing the matter from (he i^'eneral point 
of \-iew. as Mion as their jireseiice is noted to any material 
extent, thrir removal for aural prophyl;ixi> alone apjxar^ 
undoubtedly to be indicatttl. 

ThiTe exists, however, a certain num'ner of cases in which 
removal of the adenoid \egetations in noii-Mi])purative disease 
of the middle ear will be unattended by any good residts on 
account of the advanced stai^e of the aural disease, as t wn in 
children cases of sclerotic middle-ear di>east> occur. hen 
a catarrhal deafness has ccasei! to be ammablr to treatment, 
no ben(>tit as far as the hearing i> concerned will fellow the 
clearing away (»f the■^e growths. 

For the undertaking of operative pro( edun's for the re- 
moval of intranasal deformities or for the relief of deatncss. 
the indicatit)ns are easily and clearly .leliivd. Speaking 
gtiierallv. unless it is jiossil'le to im]n-ove the hearing by means 
of an mtlation iiy the ICu-^taehian latlutcr or by polit/.tTi- 
/ation, the rem()val of hyj)ertrophi(-> (4 hr imudus membrane 
or <leformitits of the M'plum is luit , kelv to attord any anr.il 
• iiiu hiuation. liitr.m.isal suig(i\- may lie und.rtakcn with 
■idvantage i! it is ])ossible to render more lasting any beiielit 
obtaiiK d from sjut ial atti iition to the ear. 1 his may be said 
ti) !)(■ so 111 most cases. es])e( ially those ot (atarrhal deafness. 
uh.re nlitl li.is followed intlalion of tlir ears. lleie the 
unioval of the eiilargrd ]. ist.rinr ends ot tiie interior tur- 
iiinates is of all operations the most ttfeitue. botii in iin- 
]irii\ing hearing and in the n lu f ot tinnitus. especiall\- wlieii 

the JiMtlellt eomi'l. Ills ot a dull sells. ilKMl 111 tile legli-ll ol the 

mastuid ]irocess. 






46 



// 



IXDIiOOK Ol- DISEASrS OF TIIF. FAR 



i 



In aural lliorapy. the removal of spurs, the correction of 
cle\ iation of the septum, and the reduction of enlarged inferior 
turl)inates to their proj)er size, have for a further indication 
the necessity <>1 a tree and straight ])assage in the inferior 
meatus for the purjiose of tlie intrt'duction of the Eustachian 
catheter when even by modifications of the curve the surgeon 
is unalile to pass it. The ilirect l)inefit to the ear in these 
cases is doul)tful. and the oinrator shoidd be very guarded 
and clear in his prognosis as to the curative effects of any 
meiisures directed towards correcthig such pathological o: 
abnormal conditions. 

Th(> use of nasal iriigalions in all cases of atroj.bic or hyjior- 
trophic rhinitis, when combined with non-supinirating middle- 
ear disease. shoul<l be a routine direction. A judicious use of 
thi^ galvano-cautery is often beneticial. inasmuch as, though 
its results are not jtermanent. the improvement in hearing 
obtained after its I'miiloyment proves the p()ssil)ility of opera- 
tive measures of greater extent being useful in the same way. 



fl 



CHAPTER 1\' 

ESTIMATION OF TKE ACUTENESS OF HEARING 

Tin: most essential part of the aurist's art lies in the ability 
with which he is able to apply the necessary tests for iiseer- 
taining with the great' st accuracy the state of the hearing 
])ower of the individual n. the road to success lies in the 
thorough comprehension of the meaning to he derivetl from 
those tests ; therefore it is above all imi)ortant that a thorough 
knowledge of tlu' jiractical ai)i)lication of thesi' tests be 
aL(iuired by constant practice, so that experience may cnalile 
him to ol)tain the l)est r' suhs. and to classify scientifically his 
ol^servations. 

\\\' liave at our dLsposal many means, mechanical and other- 
wise. l)y which we estimatt both the relative and actual state 
of the acuteness of hearing. The following are the media 
principally usetl : The human voice, tuning forks, the watch 
or acoumeter. Galton's wliistle, Edelmann's pipes, Kiinig's 
rods. Stultz's inonochord. an<l last, and of by no means the 
least value. Marage's syrens. Of all ti. se methods of testing, 
tlie human voice is by far the most imi ortant. but. most un- 
fortunatcK ■ it is at the same time the hast satislac tory in its 
results, since by a careless use it may di inon>trate improvt - 
nicnt where non- ^ msIs, or, on the other hand, no increase in 
the hearing power lor the voice is noted whca other tests show 
of its existeree. 1 his is largely, no doubt, vni .k count ot tiie 
want ot ineihodK.d training on tiie part ol lie aurists. Hut 
it is .ilso bv no means entirely due to that cause, for voices 
vary in their clearness as muciias. or more tlwri. musical instni- 
tm-nts. It is impossible to standardize voice tests, nor have 
we any formula wlii( h wiii . luce to a (()mn\on level all te-.1s 

47 



48 



ii.t\i)i:(>(U< (U- i)isi:.\si.s III- iiii: i:.ii^' 



iiKi.lr hy llir s;ini.' voicr in rooms of diffrrful >iz.'S aixl ol 
(littrnnl ;udustic iiroiurlio. 

All s.nin.ls possi'ssiiiL; the same nuinlHr ot vil.r.ii i<in< p-r 
sccon.l. thnu.t^h i.ro.lu.r.l bv various a^,vn,u .^ luivo .lillmn! 
clKiractcristi.s. Wv wliuli liuv may !"■ .lrt,rtrd or viMr.tr.l 
Irom om> aiiotiu r bv tlir numan .ar or by mr.lianical m. aii^. 
It must follow from tlii> that all tlu'M' s,,uiul w.ivo tliou^ii 
-iviiiK the same numbrr of vibration> i..>r mtoikI. uuM luivc 
wav.-s .mviiiK a .liflcn'Ut curvr. An asMnnption is iu^tituMl 
that those -.'onn.ls. havinj^ ditfcrmt .inv.-.. whose vibrations 
are the same in number per Mroiid. will v.vh not only have. 
lH>i<le^ their different wavs. a (lifferi'iit peiiet rating' power, 
m t he same wav that lights of (Ufferent .olonr. but .,f the>amc 
intensitv. havi- different powers of penetration. For ihis 
reason th.' sound prodiu e.l by a lumiii,'-fork. a whisilr, an 
..rj^an. or a strui:^. will otteii i;ive different results when a 
paUent i> le>t.d with two or more of them. F.h" the present, 
however, lor ].raelral work ..n.' i> lies upon th.-.. ui-dia lor 
listiiiL,' to whi( h w. h.ive alread.\ alluded. 

Testing with the Human Voice. In testinL; with th. human 
voue, the exaniiiur stan.ls .,n on.' side .,f tlu' ])atiem. uhosr 
„ther .'ar should be tightly elosed by the insertion ol the 
hnrer. and eare must be taken that the patient is unable to 
,,l;serve the mouth of the examiner. It is also w.ll to keep 
,!„■ lutient standmg at least J or ; teet from a hard wall; 
Put if the iiati.'Ut is >1andin^; against a eurtain there is no 
neeessitvlorhim to be ivmovMl anv distan..' tr..m it as in the 
|,„nirreasr sound ma\ bcl, tl<te,l troinlheuall ulurcas the 
, .iitam would bnak up the s,,und uaves and pr-veiit .mv re- 
„,,,„„, ,,, ,i„,„. Simple words niakeilieb.st test, and thos,. 
sliould be s,„,k. u m su. h a av that the \ ,n ions s,,unds ar.- 
,.,|uallv .nii.love.l an.lthat t h,' w ..r.U aiv m..i. .'i !.sskn..'.\n 
,,, ,!,,■ path lit' It mav h. n- b. r.niark. d that wh- n .haling 
with pati.nts lr..m ..th-r i^irts ol th.' I'.miur. wh.i. ih.' i^i.. 
,„„„i,,,,.,n varus v. , \ mark. .Uv Ir.Mii his ,,wn, t h.- . xanim.r 
,s x,i\ apt tobe.l.e.iv..! on a....unt ..I t h. pati. nt 11..I r. . ..1; 
UUJUK tl'ie woi.l whuh is iMing spok. n. in this tiist l.'sl t h.' 
l,.ilu nt i:. made I., up.at out lou.l t h.' MUgl.- woi.ls w inch luv 



/■>/7.1/.//7().V ()/ '.'//• ;(//7,.\7>S (ll- III Ih-IXG 



19 



4 



lircii Njjdkrn by tlir I \;uniii. iii .i ilr;ii , cwn tone -thai of 



(>riiinar\' ci 



)n\-c'i> ition. Th 



:aniintr thm inrreasos or 



wic-n lii'iisfit am 



(lliiiituslics the (li-taiicc lict 

he li.is ai 1 i\((i ;u t iic liiiiil (ll licanii 



1 t! 



jmI icilt . until 



I" 1 hat [jaticnt 



l'i>i<''^ tlic ni.-, ,> tlia! \vi> \vdvv alrr.idy i-rnlmiuHl, of 
cutiin.^ (itf t ill niin.l car or t ho on- wIik h is not l)i'inj,' • ^-sted, 
one lias now a -^i.^all u. inini. 'it uhicli i> api.hrJ, inio the 
scund tar iiilr the otluT i> irstcl. '1 his is the noist-prtnhiccr 
ol Hal-al•^■. 'llirn- is ,: mall knol hirh is kept jTcsscd. which 
■^""^^■^ ' iiiin( r ilrivcn hv ■ ' k\V(.rk to kc'cj) nj) a continuous 
^1 rirv ,,i slurp stro • on mall {vn>r mem' anous disc. 

W hen the iiaiunt i> unahic {>■ hear onlinaiy \-oicc. it may 
1)1 ii.cosary. as in casi-s of sevtii' dcafniss. to incn'asc t ho 
''■"'"in. ol ,s, nil hy sjicakinj; m a louder \-oici'. On the 
othrrliai oui has i-miil(.\ a lower \-oii 1 lian t hat ol con- 
vci-sat ion— that i^. tlr wh per- in older to detect tlie sligiiter 
gr.-i les of loss of hearintr. and in nmre advanced cases to he 
aki> to estimate th' latmol luariii.L; !» tween t hi'con\-i rsat ioiial 
\-oice ami he whi-prr. 'Ihr wdnsper ii;'i-,t he ol very f^reat 
nnihirmily. and t hr pro|Kr method to adoj>t i> ohtaineil hy 
' inptyin,!,' tin- Iuiil:-. ol a~> imuh air as po>-.ihle. and then 
uh :ie;niK -iuf^le \- urds. usin.i; the n-.ddual air tor the ]iur- 
l'""^'-'- "lie reeoriU one'- oli>er\al ions umlir the titles of 
' l""'l ' '"' ' oidinar\ ' \oiie^ and thi whisjier as jiereeu'ed at 
t hr ri>i..iii\r disi.iiiio noted alter them, and hv rij. eating 
t Ills tent at in!er\-als t he exam.iier i> ahli- to ihtain .m ajiproxi- 
m ite ajipreeiation ol the pio^ros of any case. 

in makiiii,' t lies, lois. it is i eosary to rem inlur tliat 
<irtain \oi .il sound ' ra\ li heltei ihanothei.s. The lollowing 
'■^ 'I" oidi r. lakmi; tin lie>t tra\elhn,- sounds last : Hissing 
siliiiam-> and s,,lt (.'s ln-hly pit. In 1 ; F M.umls and explosive 
"I medium piieh ; ill , p tones, .\n ordiii).^ to (). Woll. letters 
\v hi n Used sin-l\- should he lakiii in the lollov. ing order: 
K (huKuali 1', K. I F. S. Sch. G (soli). U, D. In ..:iain 
lU.seases soiiu 1, tteis are heard worse than others. 1 iius, 
S and Sell arr hranl hadl\- m dise.ises ol the idnduetiiig 
ai'i'.u.Uiis, wiiili ]• is so 111 l.ihvnnlhine disease, ami K in 
'''■''■'Is ol the ill' iiilir.me '1 hi w liis]Hr is more rapidlv lost 



'iii 



fl 



fl 



50 n.ixi)i:o()i< oi- Di^i-.isi-s <u- Till- r \i! 

in ini<hllr-.;iv .li>ra>t' ami ..Iom!. ro>i> than in i.i(iL;rr>>ivo 

nrr\'f li'^inns. 

Continuous-Tone Series. I'.v a r,>ntinr.ous-tnnr -.ri>s is 

iniplli (1 the use nt all llu' llnU- invluMVc oi srniitdncs. in llu- 
wlu.lr xalr. tinni Mxi-.n d.iul.U' \il.r;ii ioiH uimards ; but 
tluiv aiv ViTv tfw ]'ro\,\r who tinplny iiKnv than <>nv tunin^- 
|,,rk m ra.h .ntavr. lul Ivi, lni<tn,t'> pijKS an-l (ialKms 
\shi>tlr ailonl a ront inucn^-tonf scri. s uwv many dctavrs. 
,,,nuni n. in.u at C, .:3" 'h.uM.' vilmition-^. Thor \<\\n-> which 
ai-f (.11 tlu' ha>is ol a cIom.! orj^Mn-pipr. aiv cajuhlr oi hnnK 
rl,,nf:attMl. and llir inoiith ..! tli.^ pipr can he altnvd in M/.f 
I'.v nuan> d 1 hnv iiipcs a comiiuiuu- s.ru'S ot toius iiiav he 
.,l',taiH.Ml. cnnimnu inv; at C" in t hr low. ^t and nidiiiK at A' in 
ihr >r. (.nd. -ilu' hiKlust (.1 tlus.- iiiprs coninicnrcs at <.r 
ahout A', and trniiiiiatcsat tlic liiKhc>t au<liMc not.' rajMhU' 
(,1 Iving luard hv tin- liiiinaii <'ar- ol 5(1(100 vibrations ]H'r 
scc(jnd. The lower-tone i.i|H> are einiiloved in provinf; the 
existence oi 11. rve le-ions. lor it will fre.jiK ntly be loniid that 
,,ne (ir :'ore iiot.s will not be luard. llie highest one. or 
(,alton-l-:deliiiaini wb.i-tle. i-. emi'loyed to detect the upi'er- 
1,,,,^. i„ai,. and 111 ca>e> ot nerve le>ion> this will be con- 
M.ierably lower. d. thoni;h a Lav npiu r-tone limit must not m 
itM'll b." consi.lere.l as a sif^ii ..1 dis.as.-. lor m the human 
b.inf; individiiaK wliose h.-aring is in cv.iv way k""-1 ^^^iH '"' 
{(Uiiid with a low-ton.' limit, and it this tone Innit is sutViciently 
l.Av. ai^i'i-eciation ol inu>ical-strinKcd in>tniments. whicli call 
into ..MM.iue v.rv hii;h harmoni.s. as an intcf^ral la. tor in 
tlir prodiutioii (it that auditory s.nsation b'.^m uhi. h i^l.^aMir.' 
is .l.riv..l. will be impos^ibl.'. 

Marap's in>trnm.n1 ..m>ists ol a s.'ri.s of syi.'iis u.uk.'d 
l,y an .l.-lro laot.n- uhidi. K.^eijier uith artUi.iaJ. naso- 
|.ii,ir\n,U'al .aMti.>. at. .a^abl.' ol pro.iu.inK the iirmcipal 
vow. 1 s..im.U. or soin. tliii!^; r.^. mblmj; them so n.arly, as to 
be pr.ictically as j.;<'<'(l -'^^ 'l'>' human voi.e. lie has abo dials 
uhuh ^i\e th. amount ol lor., or ml.usity r.-.iuiMt.' to pro- 
du.-.- th.' note .milted i'V ih. sNren m u... an.l by this means 
,,n,- is abb to r.'. .'fd HI a .ma.phic m.imier th.' various sounds 
ami how ill. V aic luar.b 



j:stimatiox of the acvtesess or iieaiuxg 51 



The Watch, or Acoumeter. — Thr uoouiiKtcr is a small 
instrument invented l)y Politzer. in which a short metal bar 
(Fig. 21. {■) isstruckby asmallliammer (Fig. 21, A), and. ;is all 
aroiimeiv.r.-, are made exactly to the same pattern, a uniform 
sotmd is arrived at. tints enaliling oh.servers in all parts ot the 
world io express their results liy one statidanl. This instru- 
ment should consequent 1\- l)e used whenever jjossible in 
jMeleri'iice to a watch. If. however, a watch is adopted, the 
observer should carefully test tln' limit of distance at which 




I I ! 



! 



Ml 
I 

i 
I 






MC. 21. — l'OLM/l;U S .VCOU.MI U.K. 

.\, Disc for applvini; tt) mastoul ; H, luuiuncr ;' C, motal l)ar ; P, lever; 
I'., •^1()p to insure constant strengtli of slioko. 

the tick of the watch is |)erceived bv a ]>erson with normal 
hearing, and any results he re<(irds ^lujuld be in the form of 
.1 fr.iction, with tiie limit <if distan(e m inclies as the de- 
uttminator. As the watch j^i\(s a more musical ^^ound tjian 
the acoumi'ter. thr residts obtaiurd in .my cas. . if both are 
employed, may noi correspond. 

In e.vamining witii rither \\.itch oi acounietrr. the ear not 
I'eing invotigated imist lie linked. Tiie iiistrumiiit is then 
|il,i(('il (lose to till' ear. and moved steadily away until the 
Miuiul Is no longer [)erceivi'd. Undotd)tedly by this means 



52 }i.]\iin<^<u< oi- nisi'Asrs oi- rin: /:.i/o 

the i)atifnt is, a-, it wcrr. iiMc lo follow \\u- xnuul fiivthor than 
il thf instnimfiit is f,Ta.luall\- aiiinnarlud to the car ; but 
whrtlicr tlif watdi \>v rcniov.'d ivoiu or ai.jiroadird lo tin- 
ear. Huil victhod must he m^id'y .idhocd to. In tln'- t>st a 
silrnt room i> more important than wlun n^ini; llu' von >• tot. 





II... 22.--LVCM:s IK- ->,■ VKOI r-^-^OU LCCAi: S l.\T\ <T VOKK. 

n ninl;-! OKK (c). ^^^^. ],.|, i,;i„,| iimuk' ■-liciw^ llu- li.mumi .it icst 

pHl I'. 



imic'il \(i \il';,i1r (\,u11\- llii- inimitr. .nul 
Jul- clniuii.iti-- till' pcr'-on.i! t.u lor. 



A source ot l.ill.i. \- in tlii> tot lic^ m the ia( 1 tiiat il the watcl; 
or aionnii'ltr bi' apjiroat lu il to within ; Itct ol a u.ill the 
soiiik! w intinsilir.l to tlir listciur. ami the luaruif; diNt.tiue 
lliiis imulc <inilr futitious and mi^Ir.idin^. 

Both Uie human voiic list, an<l tint ol the aidunulu 



/•:s/7.i/.(77().v oi- nil: aciti.siss oi- iii-.tinsc, 



33 



>linul(l Ix' ri'[)('atr(l ;i[t(r inflaticm (it llic miildlr tar ami any 
iliffcicncf in the results noted, as having; an important 
lirarinp npon the diairnosis and i>n)t^n(isis. 

Tuning-Forks. Tlu' examination ot tiie patient's acnteness 
oi hearing;, or the estimation ol his relatiw dcalntss. dejiends 
in a \'ery lari^r meii'-un' on the skill and kno\\lcdf,'e whic ii \v<' 
hrini.,' to hear in the employment of tiniini;-forks. and the 
eomprelunsion ol th( rrsults so ohtained. and. ahoN'e all ujion 
a clear nnderstandin,^; ol the heariiifj; of tluse resnlts u^jon 
those deri\'ed trom other \'arirties ol tcstins,'. 

The note (»r ]iit(h of the tunuij^'-fork most tistially emploved 
is either (' or A. The C tiniinj^^-fork has. perhaps, the ad- 
\'anta,i,'e of beini; tlir one more eommoiily emplo\-ed. owinjj; to 
which a com]iarison of the results oiitained by different 
()l>sor\'ers is the nion' t asy. 'Ihe pitih of A. ho\\e\tr. has 
the merit of not heinj.,' in harmony witii tin- more (ornmon 
sounds of trattK and sU( lidikr. and so is more easily dis- 
tinguished li\- the |)atitnt. l^ut it i^ adxisaMc not to employ 
tuniuf,^-forks of ditferent notis mdess they are eniplo\-((l in 
all tilt octa\-'S. 

If it is jiroposcd to em|iloy on!\' two forks- the mininnini, 
th.it is to say w ith which au\- intt'llij^'eut work can lie done — 
the fork of (' of i_\S ami ot ('-of 512 \ ihrat ions slK'iild In- used, 
or the A forks in the cornsjiondiim octa\-es. It is wt 11 to 
remark here that whm 011^ spe;ik-^ ot the \ilirations o' ttming- 
iorks donliK- vibrations .iri' iimler>tood ; \\herea.-« in all rither 
instruments sinj^le \ibr.itions arc alluded to an nnnei'c^sary 
Kimp.lh atioii. but I ustomar\'. 

In onhr to obtain the most regular and delniite results 
from luniuL^-fork tests it is ncjuisite that a tork not only ot 
absolute aecmMcywith legartl to pilch, but of a re^ulat ion form. 
~i/,e.and wt it;ht . be tis( tlfor thic hiel or fundamental tests. The 
tunin,^-forks which hot conijily with tlieNc conditions, and 
which tiillii our I'l i)uiniiients. are th(we ot hucae. ( )f tlux-, 
th<' one depu ted ill hit;, jj IS Hit A] leiisive. and will aiiswir ^dl 
jitirpose-.. but i^ --eeii ill h'if.;. _'_; in its l.ili st ami most reliable 
lorm. The partiiular atlxaiita^e whiili tlii> hitter fork pos- 
sesses when t (iiiijiart il with otheiN is ih.it th.e spnni; whiili is 



f 



li 



54 



Jf.lM)l!OOI< OF lUSF.ASES OF Till: I:. IF! 



used to jirojtcl tlic li;iinnur which strikes tlie tuniiiK-fork and 
sets it in vil)ruti(>n i> of the same strength in all cases, and 
thus the uniiiii;-l(iik t .m l-e acdirati ly tiii.ed to vibrato 
al\va>s through the same period of time, l^y this means is 
eliminated to a threat extint the jieisonal factor, and it is 
rendered difticnlt for errors to creep in when this fork is used, 
althongli ue lia\e proliaMy not \-et .irrived at ol)taiiiing an 
inexpensive and thoroni,'liiv relial)le stamlardizi'd fork which 
will inxariahlv ,t;ive .xadlv the same results as any of its 

fidlows. 

The other forks which are employed commence at the 
lo\\(St (' of Id doul)le viliration> ]>er second, and a^end as 
luf,'h as ('" of S.i()2 douhk' vibrations per second. In emi)loy- 
in^' the ordinary tnninf.,'-forks--that is to say. other ban the 
fork depicted in Fig. ij— the following direction should be 
carefully obser .ed and invariably followed : 

The fork is to i>e struck with or 11)1011 a hard substance pro- 
tected by a soft covering, and the point of imjiact >houll be 
nearer the shaft than the ti]i of the jirong. Before jilacing 
it on the ]>alient'> head, it slioidd be listened to by the oli- 
ser\er. in ord<T to be sm-e of the absence ot overtones. 'I he 
])ra(iical inii'ortance of this caution lies in the fact that, if 
the test is made with a tuning-fork emitting overtones at one 
time and without doing so at another time, the })atient is for 
all practical purjioM-s being examined with tuning-forks of 
different pitdies. In testing with a high-pitclu d tuning-fork, 
the oliser\i r nnist not strike the fork too hard, for if the note 
is above a ei rtain inten.>ily. it will l>e |)ercei\-ed by the sound 
car, e\-en if il be occluded as mucli .is jiossible by ib.e linger, 
well moistened, and iiisi ited into the ine;:tus. Thus, in the 
case of (' • ot 1 *<-4 double \ilirations the tuning-fork must 
not be strut k in mu h a manner that it viiirates tor over 
thirl\- se( onds and m the ( ase of (' for o\-er loity-!i\-e .Mtonds, 
Thi> tlie writer was able to pro\-e m a case in which the whole 
meinbranou: cochlea, tog.'ther with its lion\- ( oxeriug. had 
iH'eii n iiiox'ed ill a ease ut !ie( ^..-.l^ ,,t tile laiiyriiilb. In esti- 
mating. ho\ve\er. tile bone loud' tiou. it may lie n<'cessary 
to strike the fork extniiieh- hard in order to be able to stimu- 



i:sriM.rii()x oi- I'li: .icrri:xr:ss or [iharixc ^=, 

hitc ail aiulitciry iar\'i' wT.osr puwcrs of ^(Jiiduction arc almost 
ilcslroycd. 

Air Conduction. W'hi u {he ohscrvcr is estiinatin,i( the air 
condiution ><{ thr jiatiint. tlu' tunini^-fork must a!wa\-s 1r- 
held lo the car ill \hv sanu' \\a\-. wilh the tij) of one of tlie 
l)roiif^s (lose to the jialiciit'^ cxtrni.il aiulitory nnain^. If 
tlif oi)scr\'iT is not nsiiif; one- of tiic tunini^'dorks ol I,uc;ie, 
wliicli is causrd to \iliratc li\- the sprin,:,' liaiunifi'. and is 
olili,i,'t'd to use his own i.owcrs of |nrrc]ition it is well tliat lie 
siiould. if possiMf, Ik' tr^trd hims.ll, in order to asicrt.un 
wlietlier his i)o\vers of pereeptioii hy air coiKhutioii are normal. 
Otherwisi' he will necessarilv olitain fault\- results. In notin.t,' 
the time duration of air condiu'tion it should he s' ;,■(! in 
seconds and not ,i;i\'en as ' norma!.' ( lecasionalK' it will he 
found that the pereepti<in of the air eonduetion of a tuniuf;- 
tork will he lon,L;i'i' than is usual. 

Bone Conduction. The base of a \-ihr<itiut,' iunin,L;-foik is 
a]ii)li((l to the ]i,itieiit's mastoid, and as lar as possible is 
always ai)]ilied with the same amount of lirnuuss and in the 
same ]iosition o\'er the mastoid antrum that is to sav. c lose 
behind the aurii le and on a le\-ei with the top ol the external 
meatus. The reason for selectin.i: this p.u'tieular spot is tlia.t 
the strueture of the mastoiil itsell varies < ousideiably either 
from it beiuij; so ludlow as to consist onl\' of a tew lar^^'e (ells, 
or b( inu of uniform density- and formed (jf almost eompael 
bone ; but it the base of the N'ibr.lt iu,i; lork lie pi. iced o\-er tho 
mastoid antrum, one obtains the most e(|uable (duditions 
possible und<r the cinumstaiiees. I laxiui; so placed the lork, 
the patiiut should be directed to raise the liaml or tin,i,n'r the 
moment he ceases to hear the sound. Viut he should also be 
lautidiied not io coufuse a leeliu.i; oi \ibr.ition with one of 
the hearinj.; of souixl. Wilh the latest pattern of tuuin;4-fork 
the duraiiim -if bone ((induction is simply checked by a stop- 
watih. and the results recorded acioi'diU!; to the iinrmal 
duration for that particular fork. l>ut if the noii-mec hanu .d 
lorui ol lork is employed, as sodu as the patient's hand is 
h( id uji, the tork is rajiidh' trauslerreil in ihe obscrv'er's 
mastoid, and rice rci'sa ■ and ai cordiag as the obhcrx'er hear-i 



I I 

i I 



MICROCOPY RESOLUTION TEST CHART 

ANSI a.d ISO TEST CHART No 2 



1.0 



I.I 



1.25 



ijr 3 ? 






1^ 

■ 40 



1.4 



[ 2.5 
| Z2 
2.0 

1.8 



d /APPLIED IIVHGE Inc 



rh U609 USA 
• Phont 



I! 



ii 



56 IIASDHOOK OF DlSr.ASES 1- III I- IIAR 

it a longiT or a shorter time than iIk pa\' nt. so xhv rocoril is 
iiuuli' on tlie testing ehart as minus 01 jltis tlie number of 
seconds wliiih re]>resents the difference. If thi' ])atit'iit's 
hearing and ihe observer's liearing l)y lione conduction are 
represented by the same (hu'ation of time, it is latter that this 
be expressed by ±0. 

'Idle duration of soimd liy bone conihiclion is influenced 
l)y llie relati\'f strength ot x'ibrations wliit li arc able to exert 
their inthuiiee tluMugh the perilj-mph on to the organ of 
Corti. Under certain conditions, if the prcsstire on tlie stapes 
is increased and conse(iuentIy tlie presMire on the peri- and 
eiido-lyniph is sul)ject also to an increased pressure. boiU' 
conduction will l)e diniini>he<l. ami this roult will be increased 
if there is .in\' interference with the free passage of air through 
the luistatliian tubo, 'I'iiis is >ho\\n ( linicallv liy testing 
jien-ions l)t'fore and <luring their slay in a compnssi>(bair 
chamber. And from this, as we ^hall >ee when talking ot 
(h Ill's te^t. that iixatiiui nl the ^tajxN may be asMinu d undei 
certain (ondilioiis. and ciin--e(|uently the loss of it> safety- 
\al\edik*' .ictinn, which piobably has the effect of diminishing 
the hearing jiower. es])ecially should the piri- and eiidddymph 
be at all e.\ce>-.i\-e ill (luaiitity. Hut whether the ( onxirse 
holds good, and the diiuimitioii nf intra lab\rintliiiie tension 
may <»( c asidually aiiount Inr increased bime ((luduitKin. i> 
not known, but it i> ( xiremeK jirobable. m \ lew ot the eheit 
ol the los-, (il tluid in ( eri.iin lung -tanding cases. 

\\ 111 11 iiii)'ln\ iiig the tuning l(irk win tin 1 in air ((induction 
or I II HI I < (Hidui t um. it i> well \i\ remove tjir invk hum tin- tar 
Iroin imie to time, in crder to ii>t tlie audildiy miAe. idi- 
lre(iui 111 1\ in 1 .I'-i s w hi n 1 Ik alie( I icn i> iaigi 1\- nl the amliloiy 
neiAc. tli< nei\e .Is we >hall Me. beiduii s ( asil\ str.iiiied. and 
for thi> ii ,1^1111 It Is well to mak( obs( r\ at khis, bdtli with inli 1- 
rniiled and willi ((inlniuinis lists. 

ibis (|uistii.ii III nil leaded bmie 1 (ludiii 1 inn presi nts ex- 
tremely interesting problems, and it is \n l-e !i"ti. ed tb.il bnth 
in iiillimm.itoiy and in snbinllaunu.iiui \- 1 (inililums nl the 
midiile ( ar this iiii reasi d bnni innduilKin is piis, nt. it is 
.L,. i.r. _. Mt ,, 11 1. 1 1,. 11,, ,, ._. .1 ,1. 1,. ,.,. .,,,1 1 1,,, 1 ,,. .. ,.l 1 !>.. 



riSriMATlOX OF THE .lCl'Ti:XnSS OF l{i:Ah'lXC, 



lioiie and iniildlc-car structvires pri'sent in otosclerosis and 
selenitic ehanj^es in middle-ear diseasi' ; and. again it is 
present in acute and most cases of chronic ol)strncti<in of the 
Eustachian tulie. as well as in certain liy[)eriesthetic statis of 
the cochlea. If a Eustachian liougie is introiluced into the 
Eustachian tutie. l)one conduction is prolonged in most casts. 
In llie same -vay- if the exit rnal auditory nii'atus is obstructed 
with the hngiT. or any similar method. Ixme conduction is 
again increased. Erom hke causes hxation of the stajies. in 
tile oval window, wliether that tixation lie honv or hhrous. 
and also when the set(indar\- membrane in the lound 
window becomes thii keued. bone conduction is increased, 
jirovided there be no destruction invoh'ing the auditory nerve, 
or cochlea. 



Special Tests. 

Erom time to linu' aurist-, of \ari(ius nations hax-e eNoh'ed 
Certain ( (imbiu.ition> ot air and bone conduction to birm 
certain specilic lornniliL', Irom uliich their experient c led them 
to make certain deductions, It is not jiroptised- howixcr. to 
consider more of them than serins to lie net is>arv. 

When the term ' normal ' is aiijilicd to the a|i)inciati(in of 
sound, the idea ihat dUi' intends to c(in\-fy is that the sound 
perception in tin- uistance under ( onsideration lies witiiin 
certain lindts known to exist in ]ienple whose imi'al apjiaratus 
is apparently Miund but whit h ni'< d unt br an\' exact number 
tit seciiuils I'lr any spei iln tuning-bu k but liiat a little latitmle 
must be allowed. 

Weber's Test. In Weber's lesi. ihe t nd <i| the shaft oi a 
\ibr,it iiiL; luniiii^'iiii k is jilii itl nu the \ertex in the middle 
lull 111 the slvU 11 in I runt <i| the ears, aiul is mo\fd furwaiil iiiil il 
lie.ud by the patient. It iiia\- be iiei t'ss.uA' in ibis iii.iniu r 

Id tr.Ueise with ihe bilk llle lorelii'.ld bridge <i| the Uiis. 
U|'|ier ilp. Ill the ( ellt re 111 the In We I' |,l\\ . T lie pat let it is asked 
tn d.elei mine ..!i wllii 11 siile lie heals flit iliite the bt t ler. 

i his test w hli h Is (i|ll\- (il re.ll si r\li e m mie -sided de.ilneSS, 
is based nil the liilliiwing experiment : 



■ 
I 



58 



iiAMJiiooK OF disi:asf.s of the far 



tuning-fork usfd as dcscriljcd abovr. the sound will \)v iiioro 
distinctly ht-ard in tlif ohstaicted ear ; this fact is in ail 
probahilitv due to the n verheration of sound in the blocked 
passaj^e. From this test m unilateral deafness we are able to 
make the following deductions : If the jiatient hears the 
sound i)elter in the diseased ear. the trouliU' lit s in the midille 
ear. or pro(~eeds from olistructions in the meatus ; the ( (in- 
ducting inednim is faidty. If. however, he hears the sotuvI 
l)etter on tlu' healtlu' side, the disease ' most ))robal)lv in the 
internal ear, or auditctry nerve; the perceptive media are 
diseased. 

When there is nerve deaf'M-ss forks of different jiitcii may 
give different results in this test, as inlands in the diseased 
organ of Corti may retain their tunction. 

Rinne's Test consists in estimating the length of timr the 
patient hears the sound of the tuning-fork by bone and air 
conduction on either side a> compared witii the ratio ol 
normiil apjireciation viz.. with (" tuningdork (I'ig. 22) the 
air conduction is longer liy thirty-luH' seconds than the bune. 
and with ('- tmiingdork th(> air coiuhiction is longer by lltteen 
seconds than the hone. I he tollowing is the metleid ot in- 
terpreting the resrhs : 'llie test is ' p()siti\'e ' nhcii in ti disc 
oj deafness the fork is he.u'd longer when held lulore llie eai 
than when applied to tlu' mastoid. ,ui<l 'negati\e ' when the 
sound is heard h.'Uger through the cranial bones. The |iositi\'e 
tinis indi( att's disease of the soumb])en ei\ iiig. and the 
negatnt' that of tlu' sound-conducting, .ipjiaratus. This test 
is ol the least \alue when the wh.ispered x'oice is not lieanl 
\ fei t or UliW.U'ds lldiU the p. It lent. 

Gelle's Test, lione conduction is dimini'-iied in tin normal 
ear when the atmospheric pri'ssure is r.iised m the i \iern.d 
meatus b\- means of a I'olit/.er Inig, or some sU( h msi 1 unieul . 

'llie \-allli- of tile list Ills 111 llie I.U I ill, It ll tlie lootpl.ltc' ol 

the stajies is ti.M d im sueli dimmiit 1011 ot bone 1 oiidiii t lou 
.1. ' . . . 

I.IK' s I II. I' 1 . 

The Proportional Test. Ibe posmlaie oi Kimie lets Imcu 
in existeiHc for fitly li\e \-ears, and during tii.il jieiioil lia^ 



I 'iii I l«ii ^v I Y 



ESTIMATIOX OF THE ACUTENESS OF HEARING 



59 



rcli;il)lo law. It is. howevtT. cajialilc of lieing used as the 
liasis from which the al)ovc-nainc(l test is evolved, and I have 
elaborated a series of sul)divisions of Rinne s test, which I 
have named the proportional test. Each subdivision has 
its group symliol, under which title one is able to classify 
most ])athological conditions affecting the hearing, and to 
make the grou])s to a large extent pathognomonic of specific 
conditions. The series is ol)tained l)y considering the differ- 
ences in the relative ratios or projiortions in which the air 
conductions and the lione conductions stand to one anotlier. 

The following six groups will cover practically eviTy alt- 
normal condition as illustrated by tuning-fork tests, but it 
nmst l)e clearb' understood that by this test alone only a fair 
estimation can l)e olttained of the disease' from whi'h the 
patient is suffering, and that in order to vrify a diagnosis all 
the other tests which one is in the lialiil of using are often 
re(]uired before one is al)le to assert with any conlideiice tlie 
exact condition of the patient's auditory apparatus. A 
C tuning-fork of uS [).\'. is used. 



Croup 


Hone 


Air 


h'tiine Positive 


Symbol. 


Conduction. 


('on'iuition. 
Diminishod 


or Xeqative. 


a 


Normal 


Positive 


l-i 


Normal 


.Miscnt.oniiurli 
rcdih I'll 


NrL;ati\ (-' 


y 


liK rcasi'd 


Niinnal 


r'>>iti\c 


fi 


liii riMNCil 


Ki-il'ii cij 


' l'(isiti\e 
( Ncizativc 


c 


1 >imim^l!rc! 


.\()i m.d 


1 'ositisc 


< 


I >imnii>luMl 


1 )muni>lud 


Ni'gativ.' 



(I. In tills group will lie tound cases tailing under two 
categorits. in the Ihst ni \\hi(ii an' iiu ludrd tlmse ut sliyht 
and earlv nerve disease, in wliidi the loss ot ,iir ( onduction 
is \'ery slight in degree; mi t!ie ^-im nnd gr'Uij^ w^' find acute 
or recent < a>es of otitis media, wliii h may eitlur lie due to 
serous etfusion into the miiidli ear. generally slight m .iiiiount . 

.■„.l ,1, ■■..,,,,• ....... ,,>- ...... ,.f l,.t,..-vl 111, till, r ,liv,. .^,. ,1.... ),, II, 



6o 



ii.ixniiooK oi- nisr.ASFS oi- Tin- i-.uc 



oiNtniction of ihc Eustachian tuhc. witli sliglit involvement 
usuallv of the middle ear. 

/I L'nder this pnmp. in whieli perhajis the largest nunil)er 
of eases is to he found, we find many whieli originated in some 
snjipurative process, whether tliis he past or still jiresent. hut 
only when there is no serious involvement or destruction of 
ossicles or other i)arts of the middle car. We ha\-e. hesides, 
under this group symhol.a small nnmlu'r of c.ist'S which are 
due to severe lesions of the nervous a])])aratus oi the ear that 
is to say. lesions either traumatic or i)athological in which the 
central part of the cochlea ah.ae remains undestroy<d that 
is. that i)art of the cochlea iiy which the sound perception of 
notes hetween C of 128 and ('■' of i o_'4 double \-ihrations ii 
j)erc(uved. 

7. In this group increase(l hone conduction is associated 
with an almost normal air conduction. This group is common 
in all classi s of middli'-car disease and otoscden sis in tludr 
earlie>t stages, and in which the tendmcN- of sta.pedial li.xation 
is d(!ay<'ii ; htit this is sonnwhat uncertain. It is also ai>]dic- 
ahle to ca>es of suhacute inllammation of the middle ear. 
There is another varietv of cases under this group symhol 
in which one linds a form of uerxc disttuhance. ol ossecjus 
instead ol .urial liv]'ev>en>itiven( ss ot the organ ot Corti. 

(1. As soon as incre.ised hone conduction has lieconie 
ahont teii seconds or more aho\c inninal one ceases to con- 
sider the case a> entllel\- (hie to middle-ear di-i'a,>e. ,md there- 
lore thi> groii)! iii( dudes es|iei i.div the chief mimher ol casts 
ol ntosi I, I'dsis ol ;ni\' intensity or iluratioii .dthoiigh one is 
not even in this case aide entinlv lo elimm.ite tue inlliience 
of a nei\(ius h\ peia((iiisis. ( )ne deals under this liciding 
with cises lioth iio--iti\-e anil iKgatixe, [lie positu'e cases 
are those in wlm h the lle|\i element is alone pleseiit. 

e. Undei" this he.idmg .ne iiK hided ( ;niy middh -ear ,dlec- 
t ions ner\-e lesions s, < ond.iry olteil to middle e.ir disease, 
and m.my cases ol ueur.istheiii.i. so that lulore one makes 
any .ittempt at formulating .1 di.igiu.sis one should li.!\-e lirst 
inllated tiie middle e,ir 111 older to he .iMe lo (Oiltr.lst tile 
results lirlol, .iIluallM Ultlatloll. j' ol' i .\ I j I is HUMUS 1 lie pro- 



i:sTiMATi()X or Tin: .icrrrxrss or iinARi\(7 



r.T 



jiortional test wlu-n iilKd l)y otlicT te^ts will cmililf an accuratt' 
<lia;,niosis to be made. 

(. The f^'reat majority of cases under this group heading 
ari' those of ehionie Kustaehian obstruction, combined with, 
middle-ear disease, antl also cases in which the oi)stniction 
has existed inx'viouslv- though it is no longir present. And 
in this connection it ma>- be well to assume that a loss of more 
than twelve seconds of bone conduction without evidences of 
nt-urasthinia means a corrisponding loss in the conducting 
power of the auditory nervi', or of ])erce])tion in the cochlea. 
And in many cases this loss of bone conduction is cai)able of 
considerable improvement, which proves that the affeetion 
of tlu' nerve ne^'d not dwaj'S be of a permanent character. 
Anil- lastly, under this grou]) heading one hnds numerous 
cases of otoscU'rosis or severe middle-ear disease, in wliich a 
degeneration of the andit(»ry nerve or of its I'ud organ is also 
jiresent. 

Fatigue Period. 

If a vibrating Luc a<'s tuning-lork is ]4ace(l on a patient's 
mastoid, and the ]H'riod during which it is heard careftdly 
noted, and if then the tuning-fork is struck and allowed to 
vibrate for about two-thirds of the already ascertaiuid bone 
conduction, andi tlieii applied to the mastoid as before, the 
period of bone conduclion will lu' lound to be increased. I he 
increase in bone conduction is due to laligue of the atulitory 
nerve, and is the fatigue ])eriod. It probably scarcely exists 
in the healthy indi\i(hial with sound healing. Hut in cast's 
of disease it will !>>■ found to \ ary considerably, and to lie 
greatest in all cases where the patient's general lieallh is 
iielow (he average, and wheri- the eighth nerve is iiivohcd. 

It is impossible at present to lay down rigidly any ilefuiite 
rule. hut. generally speaking, one may say the greater the 
fatigue period the more definite llle inxdhemellt of the 
nerve although this .nay I'e, and Ireciueiitly is, meiely due 
to ii neurasthenic condition. 

This f.itigue period, it will be found, is cipaMe of seriously 
((impiie.itmg ivLimies test, and ii wiii i)e iniiei, wiu'ic one 



62 



nAXDiiooK or disi:asi:s of the ear 



has reason to suspect the presence of this condition of the 
easily fatigued auditory nerve (when one is investigating 
I'iinnc's test), either invarial)ly first to estimate the air con- 
(hietion. and then jilace the tuning-fork on the mastoid and 
st-e if it is again perceived, or to do it both ways, first ])one, 
and See if it is perceived through the air, and then air. and see 
if it is ]H'reeived by I tone. 



V 



Anomalous Results in Tuning-Fork Investigations. 

Oceasionallv one Imds that a patient will inform one that 
the tuning-fork is heard in onlv one ear, even when it is placed 
on the opposite mastoid. This is no doubt due to one of the 
causes wliich have bi'cn descril)ed as causing jirolonged lione 
conduction, which is present in a relatively high degree in 
that ear. 

Another anomaly is when certain vibrating tuning-forks are 
heard I inly in one ear and other octaves in the other ear. when 
the forks are placed on the vertex. This appears to be caused 
by irregular areas of disease in the cochlea and on one side, 
antl is a condition found exchisively in diseases of the cochlea. 

Patients, again, will o( i asionally say tliat they cease to 
hear the tuning-fork but still feel it. In these cases the 
patient must be instructi'd to take no notice of the sensation, 
but onl}' to report what tliey hear. 

Under certain middle-ear conditions, with involvement of 
the cochlea as well, one not infrequently linds that the ear 
will hear a fork sharp ; this is merely an indication of ])er- 
vt'rted hearing on the })art of that nerve, antl may be due to 
temjior.iry or iiermanent nerve disease. 

Fncjuently in diseases of the cochlea it will be found that 
t!ie upper tone limit, as >hown by (ialton's whistle, is higher 
th.m that ^llo\\n i)y the tuning-forks. The reason for this 
divergence is accounted lor l)y the different [)enetrating value 
of the rel.it ivesound-wa\es, the sound-wave caust'd by Gait on 's 
whistle containing many overtones in its composition. 

It will Ireiiueiitly l»e lound in testing patii'uts that the 
tuniug-lork i.-^ not lu-ard eciually well by air when it is held 



nSTIMATIOX OF THE ACI'I HXESS OF ///T.IA'/.VG f>:. 



at (liffrrent angles with regard t(> the patient's luad. When 
tills has liei'ii noted, it should he registered, so that tlu' 
tuning-fork is always employed at the same angle from the 
patient's head. This applies equally, or perhaps more, to a 
watch or acoumeter. when it is used. 

Unilateral deafness of long standing often produces a re- 
markal)le development of increased range of auditory percep- 
tion on the soimd side. So considerahle. indeed, is this in- 
creased audition, that jiressing the finger into the sound ear 
is not sufficient to interfere with its clear percej)tion of sound. 

It is consequently necessary at times to employ a small 
instrument called Barany's noise - producer, hy means of 
which the sound ear may he cut off entirely. Xo estimate of 
the hearing power of a severe unilateral character can he 
considered complete and unassailahle unless thLs instrument 
has lieen employed to verify the voice tests and tlu' air-con- 
duction tests. 



I 



Education and Re-education. 

Education of the deaf can only l)e considend in deaf- 
mutes, whereas re-education is considered for those who have 
hecome deaf after infancy, when they have once developed 
their faculty of hiaring. Both education and re-education 
are. of course, absolutely the same in every particular, and 
there are numerous means hy whuli this form of treatment 
can he carried out. It is essential that some form of con- 
tinuous-tone series should be emi)loved. There is the series 
ol syrens l)y .Marage. the electric-sound a])])aratus of Bourget. 
the harmonium of Urbanschitsch. and several others. There 
is also a very useful form of instrument made hy the .h>olian 
organ-builders. Whatever methods are employed, one should 
alw.iys remem!)er that it is absohitelv essential that a careful 
chart ol the sound ])erci}ition should he made i)efore the 
treatment commi'uces, anil that an observation should he 
carefully made with great regularity. It is better tiiat. when 
these patients commence their treatment, at the l)eginning the 
tinu- occujiied should ln' \'ery slight — not more than one to 
tiui'e nunutes — and it even seems l)etter that the >e.iiices should 



64 



if.ixniiooK oi- DisF.Asr.s OF run f-.th' 



Hi , 



he oiilv once dailv- altliou^'li. if time prrssrs. tluiv is no rt'asoii 
ai^ainst tlu' jiaticiit L;ra(luallv liaviiif^' as nnicli as [hvw to live 
iiiinutrs twice a day. It is no cloulit liottcr not to work 
principally on tliosc notes which the ])atifnt is unable to hear 
hy air conduction — that is to say. speaking' of the ])artially 
deaf. And it is also better wlun one is able not simply to 
run up and down the scale --/.(•.. to take notes in their ordinary 
seciuence— but that tlie intervals should be eni]iloyed. su(di 
as tile fourths. 

With ret,'ard to indications and c<mtra-indications of this 
educational method of treatment, one may say that all cases 
of nerve ileafness should lie considered as unsuitable, whereas 
all cases of middle-ear troubU' are lit and projx'r 'iius. For 
all tliat. when deafness is complete, from ner\'e or any other 
lesion, such as occurs in deaf-mutes, of course the treatment 
is quite justifiable. As an easy method of education one may 
adopt the practice of letting the ])atient have someone to 
stand a little behind liun. oi to one side. The attendant then 
says as clearly as jiossible certain words, just sufficiently loud 
for the patient to be able to hear them, the patient rejieating 
tlu> words. One can frequently i^radually lower the tone of 
voice as the patient j^ets more and more accustomed topickin.t; 
u;) the sounds through bone conduction. 



({. 



i 



CHAPTER V 

GENERAL THERAPEUTICS THE USE OF 
INSTRUMENTS 

Politzerization.---Tliis is a term now used to designate all 
forms of inflation of the middle vdv by means of the con- 
traction of an indiarubber \rdg. forcing a blast of air up the 
nose and into the ear through the Eustachian tube. This 
method was invented by Professor Politzer. and has the 
.idvantage of being t'asily performed by the patient himself 
or by the medical practitioner unskilled in the use of the 
catheter. This method finds its chief indication in the treat- 
ment of deafness in children and old people. It is, however, 
not so delicate a means of inflating the I'ar as by the bag and 
catheter. It is more dilftcuU to regulate the force of the air 
current, and it is impossible to confine the inflation to one 
ear. so that the sound ear may be inflated while the diseased 
one escapes. Again, those who are constantly in the habit 
of passing Eustachian catheters can do so with almost no 
lUscomfort to the patii'ut. and those who have not acquired 
the art of catheterization should lose no opportunity of im- 
proving their manipulation ; their success in the treatment of 
aural diseases will be materially increased thereby. 

To perform the act of politzerization an indiarubber bag 
of about 6 ounces capacity is the chief requisite. The ears 
of the patient and of the oliserver are connected by the aus- 
cuhatory tube (see p. Og). The patient is then directed to 
lake into liis mouth a small quantity of water—about a 
dessertspoonful— and instructed to swallow it at a given 
signal. The operator next inserts the nozzle of the bag into one 

•1 -. 4I. i„.,t ..:,l,^ \V'i<!' tbp t'lniri.i- :iti(l 



1 I 



iHJ.-i t 1 JJ. V XHJ^ 



"0 



Ot 



66 



HAXDHOOK OF /)/5/:-.).S7i".S OF T'fF. FAR 



! 1 



I i 



thumb of the left hand lie now closes entirely the free nostril 
and any jvart of the other not occluded by the nozzle of th(^ 
bag. He tlien f,dves the signal for the patient to swallow, 
sharply compressing the bag wheii tlu' poniuni Adami a^cends, 
and observing. l)y means of the auscidtatory lulu', whether air 
has found its way into the tympanum or not. The patient's 
sensations are not entirely to lie relied upon. 

A modification of this method, introduced l)y Griiber. is 
the ])ronunciati()n of the word ' hie ' instead of swallowing 
the water the bag being compressed at the moment the patient 
phonates. In children it is sufficient to cause ihem to kee]) 
the mouth ojien. and in adults merely blowing out the cheeks 
with the mouth closed is often as et'ticacious as tin- other 
methods, and less troublesome. 

The Eustachian Catheter. — One of the most important 
methods of diagnosis and of treatment is the projier use of the 
Eustachian catheter. The ciitheter may bi' either of metal or 
vulcanite, long or short balljiointed or plain. It is now 
customary to advise the use of a short catheter of from 
4.1 to 5 inches in length. To inflate the ear by its help an 
air-bag is recjuired, whh a nozzle htting well and easily into 
the end of the catheter, and in addition an auscuhatory tube ; 
it is iietter to be provided with a fine spray apparatus filled 
with a 5 per cent, solution of cocaine. The lower meatus is 
first anaesthetized with a very small amount of cocaine. 
3 minims or 3 minims lieing sufficient for either side. One 
end of the auscultatory tube is now jilaced in the ])atient's 
ear and the other in the ear of the observer ; it should be so 
made as to retain itself in position, and should neithei be 
held in the observer's hand nor touch the patient's or sur- 
geon's clothes. The tij) of the patient's nose is now slightly 
elevated with the thumb of the ol)server's left hand, the fingers 
resting on the forehead. The catheter is held in the right 
hand with the beak pointing towards the patiem. and intro- 
duced into the nose with the shaft almost vertical. The outer 
end is then elevated so that the shaft lies horizontally, and 
passed cently but lirmly back, the point resting on the floor 
of the nose ; at the moment the tip of the catheter leaves the 



Gi:si.ir\i. I iu:h'.\i'i:rri(s i .>i. ot /.v.s/7,'r.i//..\ /' 



"7 



linn upjKT surface ol the ii.ml ]ialat(' tlu' catlutcr is rotated 
so that tlu' little rinp close to its inoutli imints more or Iss to 
the orifice of tile external meatus on the .^ani'' >i<le. The 
catheter will now he t'ngaLjiil in the pharyn^'eal end ol the 
Eustachian tub'', and is maintained in its jdact- hy tlu' finger 
and thuinh of the left haud. The ol)ser\-t r now note> care- 
fully that the auscultatory tuhi^ is (iiiit(> free, for if ii tone lies 
any portion of the clothing adventitious sounds are created, 
and erroneous information deriv' d from the sounds heard. 
The noz/de of the indiaruhher bag is then inserted into the 
end of the cathettT. an<l air forced up hy sharply eoinpressing 
the hag. In tlu' evi'Ut of the catheter failing to iiigage the 
end of the Eustachian tuhe. the point may i)e rotated towards 
the o}iposite ear. and the catheter gently drawn forwards until 
it strikes against the jmsterior edge of the septum nasi, when 
a half-turn will immediately cause it to engage in the tuhe. 
This method should not he employeil unless the surgeon fails, 
after several attempts, to find the tuhe hy the previous 
method. The other methods of passing the catheter are really 
inferior to the one just described, though they are. perhaps. 
in more general use. 

Other Methods of Passing the Emtachian Catheter. — In all 
of these the catheter is passed directly backwards until it 
touches the posterior wall of the pharynx. In the first, when 
this has been done, its beak is then turned outwards so that 
it enters the fossa of Rosenmiiller. a depression just behind the 
posterior lij') of the pharyngeal orifice of the Eustachian tuhe. 
It is then drawn forwards with its beak pressed outwards, 
when it will Iv felt to pass over this posterior lip. alter which the 
catheter is immediately turned slightly u[nvar Is. and it should 
then have engaged itself in the orifice of the tube. This method 
is recommended by Politzer as being most sati'.factory. 

Another plan is : After having touched the posterior wall 
of the pharyn.x. the cathettr is drawn forwartls for I inch, 
and then rotated outwards, when the !)eak should enter the 
orifice of the Eustachian tube. This can scarcely he a satis- 
factory method, as it presupposes the naso-pharynx to be of 
uniform depth in all people. 



68 



ii.wDr.ooK (>i iits/:.isi:s oi- ri'i: i:.\r 



A Ncry satV iiHtluKl ((Ui^i^ls in dr.iwinj^ tlir i''tluttT lur- 
wanls, altiT liavinj; tdiulird the jiostirim" wall, witli its la'ak 
turned to\\ar(l> tlu' (j]i]i(isit( rar. until the forward nidxcnK'Ut 
(li the catlu'trr is (■lic(d<('d \\\ tlic posttrinr cdm' <il tli/ \-(>nu'r. 
The catlu'tcr is tlim rotatid dutwards tlirdii;^!! halt a circle 
witli the |i(iiu1 downwards. The catheter will then invariably 
lie found if projierly turned, to ha\-e lii^i^a^ed itself in the 
orili( e of the luistai hi.in tube, '1 his procedure has one threat 
disadwintatje. in that it i^ e.\treniel\- di>aj.;reealile. and often 
painlul. 

W'hiii it is ini]Hi>>ib|r lo pa>s the lui^tachian catheter down 
< ne no>1ril. c.:Ulieteri/at ion ina\- bi done Ironi tip' o)iposite 
nostrd by |i.i^-.iii,i; the caihi-ter and rota.tin.L; it towards the 
Eustachian tube. 'Ihe in^trniniiit nni^t be rolatecl at the 
moment it passes (ccr the ed,' il the hard palate, but it may 
be. and oll(n i> ne( t >sar\ to make the cni'\c- ol the catheter 
at its beal-: ahuo--t that ot a rii.;h! anije w ilh the >lialt. 

ilie ilitfn nil !t> w hit h ai' ■ m ' v\ ith in |>a'-s Jul; lie |-jwtaclu<in 
catlii tt r are due eiih( r to irri -_..,,iritii> m the na>-al pas>,ij^e or 
to irrilabilit\- ol the julate. To the e.\p( ri( nc ed hand a nose 
so n.irrow and nre^idar. that the latheler ( annot be jiasM'd 
v\itli llie aid 111 cocaine and delicate mampulat ion. is \-er\' rare. 
If iib-trm ti(iu> are im t with in pa^•^Ul^ the cath( itr in. the 
manuei' desiribed. with the bi ak on the floor, it nni>t be 
rotated either ouiw.inls i r mward> or e\en j'as^iil with tho 
point npw.nib, the (.itlntir beui.L; lieM ujiwards instead ol 
downwards al fn'-^t . and pr^ -^-ed ;^(n;ly but liindy backw.n'd. 
le^.nnniL; il pe^-^ibl. . the i (irri > I jiosiiidn alter <lea.rin,L; the 
obstnu t ion.. It i^ >omelime> ne((>--,ir\ to m.dvc a bend in 
the shall ol I In ( at heti i . with t he i nu\< xil \- on the same side 
as the loop , it Ol ( a>ion,dl\' In ips ( oiwideiabl\- to st r.ii.Lihteii 
out p.iitialh the ( nr\e at the lip. l)illicult\- experience<l in 

IoKiIiiil; the I alheti r l^ either due lo l!le ( U1\C beinj; too loll).; 

or to the p.itieiil ni.ikmt; tell-' the ^(ill p.d.iti', if the ( iir\'e 
is too f^reat the (.itliiicr mu^t br \\!th(ba\'.n anil the iur\e 
modilitd. "should. huwiMr. dilliMilt\ ,iri-i Iroiii irritabilit\- 
of the jialatc, It inav be o\eii oiiu liy llii In Ip nl i ocniie. or 

1,1' ll... i\,v,i^, 1,1 .. Ik, . ,iO I I ,1 1,11 ill. nnl .,1 ill. iiitl.lil 



GEXERAL THERAPEUTICS— USE OF IXSTRUMEXTS 6g 

Sonu'times the rulheter dcu'S not pass easily into the mouth 
of tlu; Eustaeliian tnlie. Tlie act of swaUowiiif: on tlic part 
of thf ])atient will nsuallv ovci-ciinir ihis ditliiulty. Thf only 
(lan^'cr in pa.ssin,L,' the I'atlictiT arix s lr<'ni the eni|iloyintnt of 
nnnrct'ssarx' roui^lnios. and the ri->k (on^ists in lorcing the tip 
ol the eathrt>r thron.yli tlu- nuudiis nicnihranf. Should this 
happen and inflation lir piDCirdiMl wuh. i niphy^eina of the 
palate may he set up. and it was due to stu h an aeiideui many 
years as^'o that eatheteri.sm fell into disrepute. Without imdue 
foree or carelessiu'ss injur\' ol thi-^ kind ( ,ni only liapj)en 
durin.i; a s<iftened cdndition of the mucous mendttaiie (dii- 
>e(Hiein upon an aetite catarrh ol the na>o-ph.nyn\. 

Too much care in >terili/,in.i: catheter^ cannot he ohserx'ed, 
ahhou,L;h so lar as the writer is aware Diily one i asc has e\ir 
lieiii reporied and that Ion- .i<^u in another country, in which 
a Serious dist a>e was ((uniinmicated \<\ .i diit \ instrument . 

The Auscultatory Tube. This is a im tal or rublier tnl)e 
litted wiih an c ar pie( i at eitler end. 'I hese ear-pieces are 
usiialK' of difieieiit colours. Ill order that the t x.iniuier m.i\- 

lie al)le to k( eji dlle to,' Ills ( iW 11 Use. Sij'aiMte lill-pieces lot 

till' patient of metal or i.;las> are now olitainal^lc. 'I he tuhe 
is u>ed primariK' to det( ( t the t ntraiice dl air into the jiatieiit's 
ear duriiii; intl.ition and srcdiidariK' to lorm an opiuidii as to 
the state (if the e.ir and of the |ial< ni\' ol the !-jisiai liiaii tiihe. 
It is dl f.;r( at import. inec tn leineiiilier tli.il tln' iim' ol tiiis 

tulie is absolutely lleces-.ar\' 111 tildsr eases ot disease <i| the 

miildle I ar where iutlatidii \>\- the calhiler or I'dliizer's lia,i; 
Is iiseil ld|- dia-iidsN (,r t leat iia lit ; Idr il t he siateiin nt-, dl ilie 
patient alone as id wlieilnr or not air iiilns tlie i \iiipanuiii 
ari relic d upun, c i roi is \ei\- likel\' to cue 111. I lic' lii'st c ause 
ol this c rmr is that ihe patu iil suit, vin.^ Ikuii advanced non- 
sn|ipiir.il i\ 1 dlilis media li.is iisualK lesi . at an\ rate to a 

larL;e extent, lactlle se n-^l|e|lil \ in llle inueenis lUc llllilMIle dl 

1 lie> nude lie ear. ! he se , diid 1- that sdiiie |ial ic ni^ will stale 

I lial an lias elite |e d die e ,.| (111 ,c( c diilll dl t 1 1 , u 1 1 pk asa 11 1 lie ;>S 
dl llle pi dc c --s dl intlal loll when ll h.l^ lldl lealK eldUe so, 

Aiiil lastl\- (-p((tall\- 111 hdspilal piaeiice the' patieiil ddes 
iicil alwa\s iinde island tlidieiueliK' what id exiKit. 



1 I 



f^ 



iu ; 



70 



HAXDBOOK OF DISEASES OF THE EAR 



II 



hiformation gained hy the AmaiUatory Tube in Inflation of 
the Middle Ear.— The sounds hcanl hy nutans of t)iis tulie arc 
of ^rcal use in diagnosis. Init ihr fintT a])pr('('iation of tlieni is 
only ol)taincd Isy iiracticc and cxiHTicnce. Tlu' sound heard 
in anv car on inflation \ari('s witli tlic si/.e of the Eustachian 
<atlutcr (iniiloycd and the force of the blast of air used. It is 
;dso iniluenccd l)y tlic jmsence or absence of swellini^ or 
stricnire in the hinien of the liustachian tul)t' also !)y the 
natiuT of the contents of tlie middle ear and the mobility of 
the (hum ami os>icUs. Tlie followiuf^ inoilitlcations of sounds 
ma\ be easily recof^nized : 

Muid in tlie ear f^ives a fine cre])itation : steiio-^is of the 
luistachian lube a distant and sharii sound ; an abnormally 
dry ear with a lax meml)raue an almost rustling sound. In 
obstru(lion of the Ivuslachian tnlte the stream of air which 
( nters is iiecc-sarilv small, hence the higher ])ilch of the 
>'Mmd. .X.uaiu. a large catheter and a Iree tulie causes a large 
sound ; while, on tlie otlii'r hand, a line instrument will give 
a smaller oiif. 

Diminution of the hea.ring distance after intlation is an 
'uilicat i(pn not to ])er>ist in its usi'. 

Syringing. The aural ^vriuL;.' should havi' a caiiacity of 
4 to tj ounct^. and at the iiroeiit dav may be obtaineil with 
the jihmger. a-- w( 11 a^ the rest oi the ^yriiuie m.ide ol metal. 
conM(|ucntly \»\\\'a ( a|ianle of ready sterihzat ion by lioiling. 
It >h(iuld lia\-e a no/,/.lt ( oming to a tine ti|i, and lie i)r<i\-ided 
with Iwo ^lni^•^ attach, d to the iiarrel ol liie syringe for tlie 
-,ii|)|nit III till' linger^ . -^ wil! .IN Willi mie at tlie lop of the 
I'lNloii-bar. Auiitlur iiiiiiro\cmiut i^ the eas\- detachment 
ol tin iiii//le whiili iiialiliN llw s\rmL;e to be lilled more 
n a bl\ . till bnie ol tlie iiii//,li niii--i lie ol large -v/.v ,il its 
iiiiiMiiial I lid and bi' uiadiialU ilmiiniNlii d a^ it a|>|iroaih(S 

I hi I l|i 111 111 i!e|- 1 o leilui e Irii t loll. 

In s\riiu;iiig lln- ear 101 Niippmal i\ e iUm aM' an ant b-ejit ic 
■,li(.ii!.! m\ariab!\ be u-^.. d,. I! b-.iwi\ia. the -yringing 1- 
(UiK lur till- riniii\,d "\ ua\ or a loiiiL;n body, water is 
all thai is IK ccssary and tlu' water or lot lou should be used 
as hut as 'he patient can hear i' '•■ ''■= ■■■'■'■■■ =- ■■ ';^'= 'g" 



1 



GENERAL THERAPEUTICS— USE OF INSTRUMENTS 7I 

l)0(ly or a sup])urativc disease a comfortable temperature is 
sufticient. 

To syringe the ear efftcit'iitly the axiricle is pulU-d away from 
tlic head and sh,t;htly ui)\var<l>. in order, so far as possil)le. 
to strai^hti'n the meatus, the syringe having been previously 
filled and njiended. so that any air present in the Ixirrel shall 
riM' towards tlie nozzle and be expelled bv pusliing the iii>ton 
till the water tic s steadih'. The nozzle is now laid along the 
ujiper or posterior nieatal wall and gently Imt hrndy held 
against it, and llu- eonteuts of the barrfl discharged into the 
meatus. The stream should always be fairly forcible, and. 
so far as ])ossiblr. uninterrupted ; if. jk nhance air ri'mains 
in the syringe the moment it is heard entering the ear. the 
syiinge should be removed and ri'charged. The careless per- 
formance of this simjile iirocedm-i' lias often roultcil m un- 
necessary pain and iiijiirii'S to tlu' iiitatal wall and drum, 




ric;. i.j — ACk.M. Ff)R("ii"=; lou ci.tansint, tih: f.\u wiiii 

(Oil ().N-W(IUL MOl'S, 

accidents which are avoidable, and not to the credit of the 
surgeon. The patient should always be srated while the ear 
is being syringed for whatever purjiose. 

Alter the svrinuiug has liecn comjilcted. all mois1m-( should 
be removed from the extern. il m.atus \<y means of pledgets 
(it cdtton-wiidl. 

When tlie ( ar i-> syringed for the removal of pus. it is an 
e\( tH.nt metlio<l to attach a iiieee of line indiarubber lulling 
1,1 tlie nu/zl' ><i tlie >yringe . l>y int nidmin,!; t!ie rubber tube 
d, , p witliin tlie canal the stre.im of wat.r mav !"■ brought 
direetly int ( 1 i 1 ml ,et with the v.m esses (il the iiKatus ami the 
middle .ar bmli (luieklv .md painlesslv. 

The Pneumatic or Siegle's Speculum. This instrument 
(■(insi-,ts (,t ail aural s],e. uluni v.iih the addition of a iiietal 
c\hnder aercss tlu (Hiti r end of wliic li a i>iece of glass is fixed 
t-it'..: ; hi-.!.'i.!!t.!b.v II! nbliduelv. The ( vhuder is altadied to 



72 



HAXDBOOK or DISFASi:S OF THE E.J/? 






a ])if{'i' (if nililur lulling' (■(uiinmnicalini; wiili ;in arrangoincnt 
\\licr(li\" the ;iir u itliin tlif --iici uluiii is ^ul)j(•( trd to an incrcasr 
or (liiiiinulidii (if jiro^urc at will. It is a j^ood |'lan to con- 
iicct this tulir with a Di l>t;m<iic's raia'factiiir. this bfini^ 
easier to nianipiilatc than a ruMifr has;. The instrument 
pos>(SSi> thrri' I'lffrnnth' >i/,('(l i iiilin,L;s to fit \-ariously sized 




•li 



Fir.. 25. — sirciJ s pNirMATic srrffi.iM aiiamhh 10 

I 'I I,-.1AN( 111 's KAKl'I"A(.-ri \K. 
(I. l\]v (iMkiiic !jlass-]il;itL'. 

ine,iln--i s ;ind \\ i^ dlien |i(i>viMe u. (ilii;iiii .; 1 hisei" a]i| Ml^i^ i(in 

111 the ill-trunient In the W.llK 111 llh nit ,lUh. il ii\er llle end dl 

tliL' sj)e(ulnni .1 ■-ni.dl j.iiit ol indiai nhher iiiliin,;^ is dr.iwn. 

Its U^e is 1(1 , li.il'je ihe siii-tnii |(i islillMte the r.l,ltl\e ten- 
sions iil 1 Ik \ ,U liiUs i Ml t -- el I hi niend I! .[lie, I (I dl lei t adlli sidlls 

(il the nil ml 11 , (lie III I lie si 1 ni I nil s 1 u in .it h. and In deh i luiiie 
llle ammint nl miilnhty jKissessed li\- ihe malji iis. In eni- 
plii\ 111;.; ihe instrument the I, nicest spri ulum lh.!l i an In ni.iile 
hi 1 iitt I tile nil .iiiis 1- , hiisi n. 



GENEn.lL THERAPEUTICS— USE OF IXSTRUMEXTS 73 



Aftrr \hv iiir lias l>i'<n < xhaustcil from llic rarefartinir. or 
nil>l)cr l)af;. lln' siircTilmii must 1h' gently introducfil into. 
Init nrist tiglitly fit. tin- meatus. Ilavin- wi'll ilhuiiinatcil 
the iiifmhranr llie rari'fartiur. or lia,;,'. is allowril ]>;irtly to 
n lill. which it Joes at the eXjK>nse of tlie air in the speculum 
and meatus. The (■ye will tlu^n detect any movement in the 
nii'mhrane itseh. e.^jn'ciallv if the ha^' or nirehicteur- is tre- 
(jiieiuly and ra]>idlv compressed and rela.xed. Tlie detection 
ot immoliilitx of the malleus i> much more dittieiilt. and re- 
(liiire> a hy no means >u\:\\] e\]ierii iice to eliiniiial<' error. 
In (ivder t<» .i^auLje the exteiu ot the rautje of mo\eme;it oi the 
malleus, the >i)ecnlum nm>t be so adjusted that the tip ot the 
malleus or its short jirocess ajiix'ars jirojectinf; slif.;litly beyond 
its ed,^e. lla\-in{,' carefully obtained one of these jtoints. 
espe( ially in the jiosition named, r.'jiid \-ariat ion (pf the air- 
]iressnre within the meatus will, it the malleus is possessed 
o! mobility, alter the relative iiositioii of the jxiint to the edj^e 
ot th<' spcdilum. By no other means is it possiblt to state 
with accuracy that the malleus is immov.ible. to, ilie l.ixest 
p.irt of the meiubiana t\niiiani is the posteri<.r superior 
(luadr.uit ; should the malleus be retracted, as it otteii is 
when morridly lixed, the hast suction outwards of this part 
ol the membrane will ,!.;i\e a false imiiressicu the belie! that 
the malleus has iiio\c il, when in reality nothing ol the sort has 
oc( lined. 'I his faet will lie more easily nndersto(id when it 
is re(;dl''d tliat the niembr.ma tympani is not intimately 
, lit, idled to the handle ol the malleus in its uppei halt, mid 
thus the thuk'iied tynip.mic tissue 1\ 111;.; e\:rriial t.i the 
III, die. ir h.indle takes put in .ill mdvcmeiits ol tin drum witli- 

dUt ol llei es^ity ( ( nil I liumcil UIl; theHl t(i tile lUalleUS. 

The Nasal Douche. I'nr this purpose either an ..rdirary 
ii.i.,il diMi. he ..r strait^ht k'^i^- syrin,L;e is sulticidit . 1 he use 
nl sill h a stiMicht f^lass \iui,i.;e has the ad\-.in1a,i;e of beiiif^ ;i 
1,-.., |,n,ibl( method- and where the nose is at all obstructed 
there is li s. Ilk, hlniod ol I aiisiii.u the emrauce ol (lie tlllld into 
the middle ear. It is ile.iih- suiiirior to ruiiber -\riii;;<'s 011 
,u,oiiiit ol I le.iiihii. ss. Patients should ,i]w,i\s be dire, ted 
to insert tile s\rillL;e llUi' liie liosiui winiii 1- lie n.iro.vcci 



ill 






74 



HAXDhOOK OF DISEASES OF THE EAR 



! 



or mon^ olistructed. as the ])rt'ssurc will then be reduced in 
tlu' nas()-])lKirynx. The flow of the fluid is kept directly back- 
ward when tli(^ ])oint of tjie syringe is niaintain<'d in a liori- 
zontal position ; if it jmints upwards, fluid is sent into tlie 
middle meatus, and \-ery frecjucntly sex-err licadac he is jiro- 
duccd. '1 lu' fluid should lie warmed to such a temperature 
as is most comfort aide to the ])atient. .md only sufficient force 
em{)loyed to insure a return flow by way of the other n(»tril. 
The nasal douelu' is in reality a siphon. The V(^ssel containing 
th.e solution should be ])laced about 12 inches only alxive the 
h"ad of the jiatit'Ut ; otherwisi' the force oi)tained may be too 
great, and the danger of entering the middle ear i)y way of 
the luistachian tube incm^red. 

Bougies. It is at times necessary to use a bougie in order 
to dilate (-(justric tion.-^ within the luistachian tube Tlnre are 
two \-arictifs of fuistachian bougies— one formed of gum 
<'lastic (i\( r liiun weli. which may l)e used without risk ; the 
other of ( elluloid. which are xar-elv safe in the most skilled 
liands. Such strictures lie within tiie cartilagincjus ])ortion. 
and as the catheter itsi'lf enters the tnlie for a short distance, 
it is (]nite sufficient for the bougie to be ])assed ■, inch beyond 
the nozzle of the calluter. This distance is controlled either 
by markings already on the callieler or by hrst marking on. 
the bougie tlu> length re(]uin d f^r it to occupy the whole 
length of the catheter, and then adding a mark J inch further 
on. lielore employing the iiougie. the sm'gedu must lirst 
asccitain tliat the catlu ter is ci.net tl\- jilacc d by intlaiing the 
car. 1 he dikitor :s tiien p-is^il and retaine<l in siln Irom two 
til li\e minutes, alter which a gentle inflation ui,i\- be ein- 
]iiii\ed. ni order to asci rtani tlleeffeil prudui ed. I'.ut il tlie 
operator is under an\' apprelieiisidii thai hr lias piicked the 
nnicdus uieudirane m the juislachian tube, tin subse(|Uent 
intlation sluiuld be empluycd lor frar of causing emphysema 
ol tlie t i-^-aies. 

Lucae's Probe. 1 iieae's jiribc is an instrument fur the 
apphi alien ul direi t and iniermillenl )ires>un to tin short 
jirocess III the malleus in nrder to increase its iniilii1il\' in 
those cases wiure. irom lalanliai aiilusiniis. the li.ii.ille ul 



GENERAL THERAPEUTICS-USE OF IXSTRUMEXTS 75 

tlie malleus lias l)cc()ine more or less fixinl and 
limited in action. It has at its distal extremity 
a small steel cup coated with a solulion oi ^iitta- 
jHTcha and allowed to drv. The ])r(ilH' itselt i> 
received into a hollow handle and works on a 
small si)iral spring, which t;ive> tlie ne( essary 
tnrce reejuired for re;,torin,t^ the lest mohihty. 
?>efore ]irocee(ling to emiiloy tliis method ol 
treatment cocaine is ajiplied to tlie (hum. using 
either a. 20 ]ier cent, aqueous solution or dray s 
aniline oil >olution. the latter having greater 
power of penetration. Unless th(> drum is 
an;LStheti/A(l in this way Ihe treatment is very 
l)ainfnl. The head of the prol)e is ai)plied under 
reileete<l light tothe^hort procos of tlie malleus, 
and pri'ssure is maintained for a ]ieriod not 
exceeding two minutes ; this apjilication is w- 
peated daily for ten or fomteeii days, according 
to the amount of l)enelit derived. A ]irol)e of 
some^vhat similar form, ut liaving no spring, 
is em]iloyeil for the jnn-nose of forcilily mohil- 
izing the malleus \\lii<di little operation is i)er- 
formed under an aiKu-^th 'tic. 



^11 



Air-Massage or Pneumo-Massage. Tl 



le aurist \ 



]vd> time sejicU-ate meaii^ ol ( inploying pneumo- 
massage at his disposal tlie linger. Delstanclie's 
instruments and the manual or deciro-motor 
oto-masseur. 

In em])loying the linger for ma>sage the 
patient presses the tragus hackwanls so as to 
co\-er and --hut tlie ordiee of the external mealu>. 
which litile maunu\re is npialed rapidly lor 
several mimile^, using as imu li ])ressure as 
])ossiMe when closing llie meatus in order to 
raise the intranieatal j)ressure. 

The instruments of Delstaiuhe are ]iro\ided 
witli a ruhl'er liihe terminating in a conical 
ear-piece, uilicil is lllserleii iiiin ihe exieui.ii 






7''i IIAXnnoOK OF DISEASES OF THE EAR 

iinatns. and tluii liy alternately compressing and rel(\asinf^ 
the [listdn variation-, in jm >MUe are ])r()diici-d. This method 
shoidd net he einjilnwd tor m(ii-e than twenty seconds 
at a time to commence with. The period may he slowly 
inereased witli .. dely to as long as li\-i' minutes, and may he 
repeated >e\-eral ;;;'u> dailv. 

The hand-maeliiu'' >ho\\ ,i in Vv^. z- will ,L,dve j ooo revolu- 
tion> pir minute when dri\-en at its {greatest pace. 




Il>.. J 7, lMl)-MASSl;rR. IIAND-MACIllNi;. 
I In tiilie sli.iiil.l |ir (il iiK'tal. 

When the ele( trn-mol(ir-dri\-eu ma>-^eur is us^'d the len,L;th 
111 tmie must he ( .u'l inlly (ilt-erved. commencin,L;- with liali a 
minute daily, and iMrrea-.in,t,f to a maxinnim ol twD nnnutes. 
With ihes, in-,trnment> il is oi ,uieat imjiortance that the 
lenj;lh ol the pisldU-tlirust h( not o\-er \ inch. Those usually 
soM are tiiii Idiii.^ loi' ordinar\' use. 

i-.iei trieali\-dn\en m^trumeiUs i^'ixiuf,' hif^li rates ol speed 
ar( In he iihl.Ulli d and \leld hetter results. 

I lie liilluwniu; rules may he laid down as to tlie > inplo\ineut 
oi oio-massa,L;e uiiii r lii.in Mei--i:meiie s nielliod : 



\ 



ci:\i:ir\i. rin.N M'l.rrics rsi: m- issi ur mi.s i s 77 

1. A positiw Riiinc i> \\n ahsdlutc rontni-indkal ion. unlrss 
tluif is a fixed malleus. 

2. I'ixcd Malleus.— \\\v.\{v\v\- Ivinnr's test shows. Init with 
a ])()sitivf, caution is r('(iiiisit( . 

J. All forms of car troiil)lc giviiiK double negati\-e I-iiime 
4. In no form of suppurative disease sliould it l)e em- 
ployed. 

Artificial Drums, Aids to Hearing, and Sound Deadeners. 

Artificial drum> are sometinu'S of assistance when there is 
perforation, or even comjilete destruction ot the tym]ianic 
membrane, in cases where the memliraue is more or li-^s ad- 
lierent to the inner wall of the tympanum, and at times when 
the malleus is immovable. They are either made of riibl)er 
discs or of cotton-wool. The former are either made with a 
wire stem, or with a thread attaclird. The wool artiticial 
diruins may lie compresseil and cut into discs ; these when 
fixed on a wire are known as Toynbee's. and if to a th.read as 
Field's, or the wool may t>e rolled ti^ditly into tlie form of a 
round wick, with its ends cut off or foldcil ovt'r and com- 
pressed so as to leave it ai)out l inch long. Both forms should 
lie tried dry. or slightly greased with vaseline. 

Before using any form of artiticial ilrum. all suppuration 
must have ceased for at least four weeks. The rubbin- disc 
must be trimmed with scissors to fit the perforation, moistened 
with a little dilute glycerine and water rendered antiseptic. 
Tile woollen wick is introduced with forceps and Griiber's 
drum by a special carrier (Fig. 54). The hearing must lie 
te^^ted before and after applyin,,' the drum, and slight altera- 
tions made in its direction until the l)est possible result is 
obtained ; these foreign bodies are not to l)e employ.'d ioi 
more than an hour daily for tlie l'u>t fortnight, in ordir t.> 
ai-custom the ear to then" presence. 

The various forms ot ear-truni])et .ind ol vnlcamte fans 
applied to the teeth and obtainab],' from in>trum. nt-makers 
are of variable use. and the lies! i>lan i> lor the jiatieiU to go 
and try them, sekcting some fur a more extended trial at 
home. 



78 



j/.ixnnooK OF DTsr:Asi:s of tiif far 



The iiHidcrn \;irirti('s of portaMc tt'lcjihoiifs iirc so mi- 
iiKTOTis llijit one cunnot muincnitf them hut llicy arc of 
llic ^^rtatcst vahu'. csjucially to those who suffer from 
otosclerosis. 

Sjiortinij; men frcqnentlv require jtrotcction for the cars. 
eitlicT from tlie wind in huntinj^ or from the continual shock 
of f,'un-firinf,f in covert shootinf,^ Naval and military men 
who are frecjuently exposed to the continuous dischar^a- of 
artillery should stand with the face towards the nuizzle of 
their piece or pieces, and keej) the mouth a little open. 
During ])ractice Hawksley's clay is to he much recom- 
men(U'(l. The same protection from noise is at times re- 
quired when the auditory nerve is hj'persensilive ; or for this 
purpose small \ulcanite sound deadeners may he employed. 



Xiiinc, 



schi:mi£ for ki:coki)i.\g tI'-STS. 

Dale. . . 



KIGIIT. 

Mobile 
ft. ins. 

ft. i)is. 

ft. /»,■.. 

Positive oy negative 



TKSTS. 

Malleus 

Acoumeter 

Voice 

Whisper 

( Kinne C \ , 

I Rinne C^ I 

,. , , , ) I'xme-cond". or t 

formal + or - secnnds ,, 11,1 

yL. on Mastoid / 

r.alton Whistle 

Poiitivc or iii'giilivc 



Ahsiiit, >}'tyt)uil. or 
miiiits seconds 



LEFT. 

or Immobile 

ft. ins. 

ft. ins. 

ft. ins. 

Positive or negative 



Positive or negative 



Gelle 

Air-cnnd" 
j'3C(it)) 

2C(32) 

iC(o.,) 

C2(3I2) 

C^(io2 4) 
C*(204S) 

lC'(4"96) 
I'aracusis Willisii 

* Wlnu both ol 1he-e are ne-ative. it is called ' double-negative 
Kinne," 



CHAPTER VI 

THE exti:rnal ear malformations, injuries, 

AND DISEASES 



Malformations. 

Th!': more usual maUorinatinns of the external ear consist 
either in an increase of size, or in deficiencies due to an arrest 
of development of the auricle— defects which vary on the 
one hand from quite small rudimentary nodules, situated in 
the position usually occu])ied liy the i)inna. and only contain- 
ing a diminuti\e fragment of cartilage, to. on the other, any 
possible ahcration from the lornial in size and shape. Amongst 
the more common abnc. ties may be noted the so-called 
supevnninerary auricles. \, ich may take the form of addi- 
tional projections in the neighbourhood of the tragus, or may 
be situated in the neck at the site of the lower branchial clefts. 
These are of no importance, except from :i-^ .esthetic point of 
view (Fig. 2S). When there is marked loss of development of 
the external ear. the external meatus is usually absent, or re- 
placed by a sma^l cul-de-sac , and there is no connection between 
it and the middle ear (Fig. 29). Another not infrequent devia- 
tion from the normal is the eversion of the concha (Fig. 30). 

Plastic operations for the rehef of deformity may be under- 
taken, but no precise directions can be laid down for guidance, 
as in those instances where operation is decided upon, each 
case must be dealt with as its own peculiarities demand. It 
is generally useless to attempt to restore tlie external meatus, 
as there is in these cases bony occlusion of the c.inal l)eyond 
the end of tlie memliranous cul-de-sac. Excellent artificial 
eais may now 'i)e obtained from instrument-makers.* 

* Or from Mr. H. Brooks uf Halifax, "^-'orkshire. 
79 



So iiASDiiooK oi' i)isi:.\si:s oi- riii: ear 

Tile Mirj^ical treat incut of ])r()tni(lin;4 car.-, may l"' citlur 



lonliurd in <Iiil(lrcn to tlir use of >t 



iliicli >Iioulil 



raps. ( a]i>. and t In 



Ilk 



H' constanliy worn, or o[n rali\-r nica^in'i> nia\- 



111' undertaken. A \'ertiea] se,t,Mn 'Ut of skin and eartiki,i-;e. with 
its l)ase wider in tlie middle tlian at tlie ends. i> di-^t i ted out . 
am 



1 th 



d suti 



ilk 



lie wound siitureii Willi >U\-er wire or silkworm ,^ni 
drawint; the eut snriaees of the tartilaije and skin well into 




^'^fr' 



v' 



I-IG. 28. SITEKNTMI K.\KV .MIHCLFS 

a]ipo>ition. The ears are to he held baek bv a bandaj^'e for at 
least four weeks afterwards. Or the followinir ojH'ration will 
be found extremely serviceable both in reducing their sizt> and 
in correcting,' their deformity. A curved incision is made on the 
back of the auricle, with its ajiex just in the iiost-auricular fold, 
rather abciw the top of the concha, and terminating,' below in 
the same fold at the bottom of the concha, the convexity out 
wards of this line of incision being in exact relationship to tlu' 
amount of correction necessary. 

AUei iiie leiiiovai ol iile skill ellcioseci iietweell these in- 



77//; /■:.v/7:/>'.v.i/. i:.ih' -ix/i-iar.s 8i 

cisidn-; ;i >; idinl i urvn! in< i^iiui i■^ made t< niiinatiiiL; in tli'.' 
>A]ni' pnints tliriiUf^li tlir >kin mi tin- iMUif lirliind llic car. 
'I his a;^aiii mu>t \n- rurwd. with its (iiu\-(\it\- hackw ards, 
and nnl^t ,[Ut> ]»■ coiiuncii'^uratf to the ihtori'.iity. An 
rlh|iti( al piicc 111 the I art ihi,!^!' i-- imw- rciiinxrd. tlir ainii Ir is 
hild, lorw.trd and th^ iariilam' i-^ di\i<lrd on to the l'ini;rr. 
taking rari' imt to prnitralr tlu' >lviii which tin iir<>>'n('c of 
till' lini^ir ^hiinld rradih' pnArnt. I lie carl ila,L,'<' is th'^n 
scpiratcd Irtini the -kin witii the handle ol the xalptl. and 




FIG. ::n. — M\L-oF,vi;LorMr:Nr of i:xti;rn-al ear. 

the [ret> ]i(»rti(in leniowd. A >iiit,'le Iniried snttn'e nia\- be 
(in|)l(i\'ed til hrini; tlu' two ed,i,n> (if the ('artila,t,fe into appo- 
-^itilln ; the skin will then he carelully i !o>ed with sutures, and 
the woutiil dresxd. If there is no Mei dint^. a collodiou 
dres^ini; ina\- be cinplowd. but it is UMiallv better, if tliero 
i> any oii/,in,L; al all. to wait tw-ent\--fiiur hours before its 
a]iplicalion. It is well to let the patient wear a wi bbini; 
bandage lor two or three weeks alter the operiition. The 
residts ol tin-' operation arc surprisingly effective. 






,"IH 



S2 iLWimoch' oi- ]>isi:.isi:s oi- riii i: iw 

Injuries. 
Frost-Bites. Tlir I'art attcctcil. uMially the lip of \hv cai, 
if sciii . aiiv. i^ fnund to l>c (U'ad wliitc ami alisdliiiclv inscn- 
sitivf. A iiKirkcd (Ic.m-cc (<i rrdiii >n in the iidjoinin;,' jjoiiion 
of the ])inna i-> mmhi iidtinil. ami 111 llic riuir^-' n) ;i few days 
tile arr.L hridims Mack, and is ultiniatrly tlirown off. Sii]ht- 
{"icial sloii^liini; of ilir skin i> vrvy (■oiiiiiionl\- lound as the 
result ol ^li^lii ho-tdiitr anHini;>1 judplc r\j osi d to sr\-(ri' 
wcatlur iiiilkim n. dri\rr^. L'tc. 




no. 30. MALFORMATION OF 1X11 UN AL lAU. 

■I. l''\('ision of coil' lia. 

Tki A I MI N r. In till in'^t iii-iaiicc. tin I'l^t ]ir(icf(lni"c is to 
alt nil I it t iir n stdiMt ion ol t he i iri ul.i! ion. wliic h is l.'st done 
li\- li.iml lr:iIion- with --now. ihr ii inrn ol (inulilion hcini.; 
liiT, dd' d l'\ a -^lAcri' l.uniiiiL; pain ^hoidd a >|i!iai rlu^ h.uc 
tuniuil. a dry drcssiiiL; o! iodotorin and rotton wool should i'c 
(Mn]>lovf<l and no undr,.' ha-tc mrd he exhibited in ri'inoviiiL: 
tliide.id 1 1 -sue so loii.u .is ]iro|'rr aul isi|itirs are eniplo\( d. 

/<i.:ii.i»:„, 'II.;. 1.1 ,..!.;,,i 1 .■ i,il.. .ir..,tL. 



Tun r.XTF.nxAL i: ar -ixjvnir.s 



83 



the oars, and requires tLj same local and f^emral treatment as 
eliill)lains in anv other ])art of the hody. 

Hsematoma Auris. The tranmatie elfusion of l)lood that 
takes ])lace in the tissues of the external ear is situated in the 
maj(»rity of eases beneath the ]uri( hondrium. and tlu' region 
in\-ol\'e(l is most frequently the ui)iiir ])osterior (juadrant of 
tile external surface ; it is common in pu,i;ilists and loothall 
])la\-ers. and is almost in\-arialilv due to clirect violc m e. A 
similar condition is liahU' to !"■ ]ir<Mluccd by very >lii^lit 
trannui. or to be aroused sjiontaneously in jiatients suffering 






i I 




Flo. 31. — ll.VM \ I IIM A .\CIU>. 

Irom insanitw 'I he skin '(i\ rrin,!^ ilie tumour apjiears ol a 
<biskv i>urpli- bur. bruif^ rarrl\- nni-m.il m (nloui. Ihe 
irnqirrature lA tbe lunt is Nlif;bll\- increasrd aini ihr tumour 
lias a i)of.;f^\- IiiIuil;. uiiIi» tbr blooil lia-- bi( n sulfuM'd into 
tile ^>ib(ut, nil (Ills .Ufolu" ti>>ue. wImii lluitnation is more 
inarki'd. 

'1 Ki MMiNi. It !-< imiiortant to note tbat n^njution i^ not 
<'ertam to take plaie. but that it it dms ddormily is sure to 
ri suit I'ur these reasons, and also on ai ount of the salrly 
uiioniiii i>v the Use of antisi i)iics, free incision of tin tumour 



f 



84 



Il.lXIUiOOK OF DfSn.lSES OF THE FAR 



; 



!ii|! 



with i'\;L(u;iti()ii of its contents sliuuld l)e uncU'rtaki'n imme- 
diately in all cast s. tlic incision to extend from the top of tiie 
tnmour to llie bottom. All the Mood-clot mu>t ite carefully 
remox'ed, il ^'Cessary with the aid of a hlimt sjioon, and the 
interior of the cavity cleansed with ^terilized or antise])tic 




II 



I'K;. J2.- UOIH NT IMIK OC l.MI'KNAL CAK. 



s\v,ili-> ;md drii d. The wmmd m.i\- tin n he mwu up in it> 
lilt rre liiij^t li . .iUi 1 lii Mi j li I ^■>uri a ppoi d 1 1\ im ,iii> < i| a I Miid.ij^e. 
^n that the aunile lie in Id fniiilv ai^amst the head. 

lie palimt lehisi- ihr rajiid i ure lo Ik 



■> lieu 111 lioWCN'cr. til 
.i .... 1 1 .. . 1- : 



'i<'<"i iiia\ in; 



ri{F. r.XTF.nyAL ear disfasi-.s 



85 



mnnvcfl hy nican'^ of an aspirator, .ind a ilrcssin^' of colloilioii 
and (,'anze ap])lif(l ()\-cr tlic whoK' car in order to ohtain a 
lair amount of pressure, \vliicli may Ix' sup]ilementrd l>y a 
bandage. 

If the tumour l)e not of recent date, and tlicre is already 
alti^ration in tlie cartilage, the serum, which will lia\e s,|.a- 
rated Irom the ciot. . iiould lie remo\-e(l hy me.m-^ of an 
aspirator, an(f a cure attempted l)y i>res>un-. if, li()\ve\-er, 
reaccnnuilation occur, incision and scr.i])ing out of the 1 \stie 
cavity affords the best prospects of success, or a little tin( imv 
of iodine may bo injected. 



Diseases of the External Ear. 

The more usual diseases affecting the external car are 
lierpes. ec/ema. erysipelas, jiericliondritis. formatiiiu of ( v->ls 
in the auricle, and new growths. ( )f the latter, pajiillomata 
U'^'K- J.;)- rodent ulcer (Fig. ;j) eiiitheliomata of the auricle, 
and libromata ot tlie lobule, are the connnon( ,st \arieties, and 
sarcom.i one of the rarest. 

Herpes n| the ear possesses no feature to disf'?! ni^h it 
Irom heri)e,> in other parts of the body. Similar treatment 
unist be ado])ttMl. 

Acute Perichondritis of the External Ear. This (ondiiion 
is, birtunately, rare, and it is always ol a septic origin. It is 
lound in neglected cases ot tnruuculosis and liss dlteu in 
cases of ( hronic unddle-ear su])puration ; and it h.is aho been 
known lo lolldw a mastoid o]ieration win n, b>r want nf iiroiier 
attention to antiseptic treatnunt. the cartilage has become 
infected. 

'1 he ear b( idnies generally thi(l<cni d sindolli .unl Lilisteii- 
ing, gr.idually beionnng 01 a (lnsk\' ( dlom', tense .mil IkiI to 
the feel. I he body tem p( r.lt nri- will !)(• l-.USed a lew degrees 
and tile pulse i|ui( keiied. ll the peril lioiidrit is is line to a 

se|ill( in|lli\- ihe imiliedi,lte course to JilllsUe is !n prninpllv 

o|i( II up the wound. .Hid b\- iiie.ms nf free iiu 1 m\ 1,, , vikisc 
and remo\i' ,is l.ir as is ui ( cssary. ami as t,ir as is pnssible. ,dl 
iufeiteil tissue. \\ liell tlie CilUSl' oi tlie Jiericliondritis IS 



i ■' ■■'« 



86 



H.IXDBOOK OF DISEASES OF TtIF EAR 



cxtt'iisioii fniin a fiirunculosis of tlie meatus, the furuncle 
nuist l)e freely n]Hne(l. sinuses follimed up. and all diseased 
tissue curetted. But wliicliever of these two i)reliminary 
tri'atinents is adopted to ri'inove the focus of infection, the 
treatment of the auricle itself does not vary. After thor- 
oughly cleansing its surface, lu'st with iodine dissolved in 
spirit of I hloroform. or 5 i)er cent, thymol in alcohol, the ear 




I-Hi. ,?3.— I'AIILLOMA OK I .Ml KNAI. 1 ,\K. 

is puni lured in six or seven phu cs willi a fine se;il]iel, passing 
com|iletelv lhroui;li the ear. ami then a moist antiseptic 
dressiug sliduld lie emplo\ri! aiid tre(iuently changed. Or 
tile ear mav lie snu an d oxer li.uk and front with ungu< iitum 
hvdrargx'ri nnd then (h-esscd wiili ;i u.nin moist dressing, 
covered I'V protective and tdtlon wool. 'I liis thcssing wants 
(hanging two or three limes ,i d,iv. During the illness, tonics 
.i!>'J. a siiiniilio mh; di. t :ire reouired and in adults proliably a 
little red wine. 



THE F.XTERXAl. E.l R— DISEASES 



87 



Abscess of the Lobule. -Al)scess of the lf)hul<' is by no means 
an uncommon ailment as the result of an acute inflammation 
of a pre-exist inj^ cyst, in most cases dermoid in ori^'in. though 
occasionally it niay l)e sebaceous, or the result of a ])uucture 
of the lobule made to enable the individual to \ve-\r earrings. 
when this is done with a dirty needle or afterwards becomes 
infected. 

Acute eczema is liest treated liy the use of a powder of 




Kic. ij, -SI I'l'iKMi Ni; tvsr (II- i.oiui.i:. 

oxide of zinc and ^tarcli. niadi' up in eipial parts, or by any 
(if tile soothiu),' ointments, such as oleate of /uic. 15 per cent., 
etc. (ioidard water is a good a]iplicalion in the wi .-ping 
forms 

If. how' \vr. tiie disiase is clironii tlie skip, of the part is 
much tliickened. and from ;,ubacute exacerbations of the 
intlanimation the auri< Ir often Itecom.-- a sli,ii.el<ss mass, 
giving ris(- to nmch di-' omfort both from tlie jiaiu and irrita- 
tion which accompanies it as well as from tlic (b^cli.uge. 




88 



1! WDi.ooK ()'■ nisi:,]Sf:s oi- rin: r.iR 



I he sanic trcatnu'iit nnist ln' carriiil oul as for an acute 
ciuulitidn. Init a.> sixjii as llic sliari.m^s ni tlic intlaininatioii 
has siihsidrd. the iisi' (if Ilrlna's diadnlon (liiUiiicut is a most 
valual)lf Iiclp, Till' (lintimnt is to he well ruliln'd in witii 
massaj^H' ol tlic part scwral times daily- wliile at iiiijlit tlic 
ear sliotild hi' wrajiped uj) in a ]iiere of linen spn^ad witli the 
ointment. (AKu riJr Appendix.) 

Eezemas liere as in any other part of the body, will often 
jirove intractahle to au\- one treatment. Strong solutions 
of nitrate ol .-.iK'er. _;() ,L;rains to the ounre. lia\-e heen recom- 
mended as a treatment in the form of a paint when the external 



11^''' 




1 1 1 ; 



i;i: ri;o-.\ii;i(ri..\K orRMoin cyst. 



nie.itus is in\-ol\-ed. Internal treatment in el Idl d c ousi>ts 

in admini-^lratinii of tonic-, in .iduliNof antiiithic-,. 

New Growths of the External Ear. W ith tin e.x.eption of 
the lihrous tumours ol tin lolaile. the-e tum(an-> re(|niic no 
spei ial desrriptiou. a.s they pos>ess un featm-(> pectdiar to 
their -situation. 

'1 lie lilironiata el tin lolnde are in realii\ k. l(>j<ls imd Idllow 
the wi aiuu; ol ( arruii;-,. W'lu ii ihe^c ( nl.ii -. im nis Income 
imsi,!;htly they should he remoxul. toi^rila r with .!s niu- h ol 
the lobule as IS uei es-.;'! V to iibtain til! ir i Mm|>lete excision, 
since it any |i.iil ol the tumour rt niaiii> it is extremely likely 
ti) lei ur. 

llie serous cysts ol the amiclr to whirli vs,. l,,i\-, referred 



i ; 



Tin: /f.v/7:A'.v.i/. /•MA' -!)isi:.isi:s 



»9 



arc hjuml in imu'li the same jxisition a.s the otluuinaioniala — 
that is to sa\-. tlir lossa triantjularis. They arc. liowcN-cr. 
siinntancous in (ir'^in tlic ttiiipiTaturi cif tlir ]Kii"t is not 
raiscil. the supcrlyi'i^ slciii is iiurinal in ilour. and tluy arc 
merely pink to transmitted lit,dit : wherc-as in tlie case of 
(»tli;i;matomata lii'iit is transmitted \erv badlv. 

The treatment of thesi' little cysts is incision and free 
scrapin,t,' out. followed ))y antiseptic packin,:,' for a 'ew days. 
If a cuttin;^ operation is for anv n ason imdesiral'le. tlu' tlnid 
contents (if tlu' cyst may he withdrawn bj' asj)iration. and a 




I'Ui. ^(). — iionNV ^aiowm of .\ii':icLr;. 

few minims of tinetnre of ioiline injected into the .awitv. 
The anricle should he jirotet led hy cotton-wool until the 
inllammatioii catistd li\' the injection has suhsitled. Cysts 
of the lohule are not uncommon, and are eitin'r dermoiil or 
SeliaceotlS. Tiny IrcilUelltlv Mijipurate. hut merely re(|uire 
dissecliuL' (Mil {Vif^. 34). Dermoids cysts ,dso (Hiur h hind 

the auiicle. 

Sarcomata ol the e\ti ma' ear are very rare and there are 
lint iii.,ii ,■ (111 r''cord_ When the\- do occui. tiie\' ma\' take 
the hirni of a fle>hv i;rowth. reseinlilinf; a iiolyjuis. spnn-ing 



i 
■3 •«ii 



go 



JI.IXOHOOK Ol- DlSEASr.S Ol- Till: i:.\h' 



from some i),irt of tlir (onclia ; tliis iiidvcs frcfly t.) tlic tourli. 
and is not iisuully very iiainlul. Wvw aj^'ain. a iwv reni()\-al. 
]iroi)al)ly incluiliiifj; llic whole of ihc external car. may [trove 
qiiite satisiactory. If tliis is done, tiie raw ana sliould l)e 
co\-ert(l with a 'riiiersch's skin graft. Afterwards the dis- 
llgurenunt can he remedied hy the employment of an urtilkial 
auriele. 



I F 



EXTERNAL MEATUS 

Acute Diffused Inflammation of tlie External Meatus priM nts 
itsell either as an extension of similar disease iiu'oKing the 
pinna, snch as erysi[)elas or acnte eczema, or it may be con- 
tini'd to till' external meatus, as in acute eczcmi or acute 
gouty dermatitis; on tiie other hand it may have I'Xtended 
from the middle ear when that is acutely intlamed. If this 
diffused intiammation is merely an extension of an erysipelas 
of the surrounding jiarts. it presents no ditficulty of diagnosis, 
and its treatment will \ary in no way fn in that tinjiloyed 
for the original disease, beyond the insertvm. after a!! ;i.cute 
signs art' ;duited. if recpiired. of plugs of sttrile gau/.e into the 
meatTis in order to restore the calii)re to its normal dimensions. 
In a( uti' eezem.i of the external meatus, where it is eoniine<l 
to the meat\is or has spread from the ])inna, a watery exuda- 
tion is formed which flows from the ear. This dis(diarge will, 
il the external meatus is not regularly and thoroughly (leansed. 
soon ix-come ofl\'nsi\-e. though rarely purulent, and is thi' 
condition often known by the miine of otitis externa. The 
external nieatn.s will i>e nnuh icdnceil in ,ize by the swelling 
of its walls, and an inspection of the deeper parts made lilfi- 
cult or imjiossible. In rare cases the swelling may extend 
o\'er the m.istoid process and rescidile an a<ute m.istoitUtis. 

SvMi'io.MS. "One of the chief symptoms in a large propor- 
tion nt mild cases is a watery, odomiess discharge from the 
externa! meatus, thougli it is soinetintes clnud\' ;md offeii- 
si\i ; I'ain and a sense of fulness (,[ ili,. ,.ar. wlien discdiarge 
will be scanty or absent ; redness, swelling, ,md an intlam- 

!li;itor\- ocilusion ol the evtirniid n.i.'.Oiw a\-,\ frcMUent :!'.', (H!!- 

pammeiits. In rec urrmg cases there is a tendeiK v to [I'^rma- 



i:.\ TRRXA I. y 1 EA T I 'S 



91 






nont contraction of the canal. Vesicles and pustules are rarely 
discernible in the meatus. In the deeper j) its of the canal 
sodden epithelial cells collect. The patient conijilains of i)ain, 
deafness, nuich itching, and of a sensation of heat in the canal. 
In children this variety of eczema is freciuently impetiginous, 
whilst in adults it is usually of gouty origin, and may be 
associated with t'czema of other parts. In clironic eczema the 
discharge is usually less, though more often offensi\e. In 
these cases the canal is often permanently occluded through 
the formation of iibrous tissue in the deeper layers of its lining 
mend)rane. Irritation is more troublesome than pain, and in 
certain instances discharge is absent. The eczema is tlun of a 
dry. scaly character, and there is no consequent contraction 
of the canal. 

Tri-:.\tmi:nt. — The constitutional treatment of this disease 
in children is the administration 01 iron and cod-liver oil. 
with the occasi"nal exhibition of rhub.Lrb and soda or hydrarg. 
c. creta at night ; wholesome food and an open-air lite materi- 
ally assist in combating the trouble. In adults a careful 
attention to the dietary, with restriction of alcoholic beverages. 
more esjjecially of beer and sweet wines, together with a ])ro- 
longed course of citrate of lithia and the regular tisc of saline 
aperients, constitutes the most approprrite treatment. 

Local Trcaimc)it.—\n children suffering from an iuipetig- 
inous eczema, the use of dilute ammoniated nurcury ointment 
is indicati'd. which is to beajiplied to the whole of the affected 
surface once or twice daily by means of a pledgit of cotton- 
wool wrapped round tlie end of a small prolu' ; and as an 
alterna*ive treatment boracic ointment will olten be found 
serviceable. In adults, oxide of nurcury ointment 8 grains 
to the ounce ol va^eliiu'. is used in the same way in the less 
acute cases ; and as an alternativ(> treatment dilute ammoni- 
ated men ury or boracic ointment is useful, and in very acute 
cases ZUK and starch jiowder. In all c ast-s the canal must l)e 
svringed out fiom time to time with weak warm boracic 
solution, 5 grains to tiu^ ounc, in order to renio\c >lied 
riiitliehuui. irritant st'cretion. and su[nrtluous ointuhut, 1 he 
tendency to (ontraction of the meatus m both acute and sub- 



02 



n.i\ni:iM)K oi- i)isi:,isi:s oi- rm: i:ar 



Ipliji 



aciilc rasrs may he (iicrkcd i)y thr insrrtion of iiidiimil-hcr 
liihcs as larp;(' a> can he inlrodiiccd into tlie external meatus, 
'lluse must he fre(]uently (■lian,i:ed. as tlio greasy matter 
\\\\'k\\ lorm.. Hie l)asi> of all ointments will soon render them 
soft and useL ss. \\\ stretehin;.' the canal, and hy pressure. 
Ihrx tuhes liel]) to disiierse the intlammatory material present 
in the snhcutaneous tissues, and at the same time tlu'y enable 
the surj^'con more easily to a])ply his remedies and inspect th- 
(lee])er parts. Thickening of the membrana tympani will 
cause a certain amount of dulness of hearing. 

In \\\v treatment of acute intiammation which has extended 
from the middle ear. jihigging the canal with a strij) of sterile 
or -^doform gauze will be all that is necessary ; and if. as 
occasionally ha])i.ens in these cases, small bulJai containing 
clear or sanious thud are foimd. they should be punctured 
belore the g,iu/.e i> introduce<l. 

Collapse of the Mouth of the External Meatus is a condition 
iound e\clii>i\-ely in elderly j.eople. and is due to senile 
changes in the tissues, which result in a vertical (dosure of the 
oi-itice of the external meatus the j)osterior wall falling for- 
w.ird.--. This closure of the meatus renders the jiatient wrv 
deal but is a condition which is easily corrected by intr()- 
dueing into the meatus a small piece of indianibber tiibing 
about \ iiK h in length, and of as large a diameter as possible. 
I'sually this may be removed after being worn for a few weeks, 
but the tube must, at any rate, be retained as long as is 
necessary, although it may be taken out and cleansed as 
often a^ is desired. 

Otomycosis. - Certain bmgi are not infre(|uemlv found. 
espe(i;dlv in the deeper parts of the external m.^atus. and 
particularly occur in the inhabitants of damp clnnates or 
insanitary dwelling-.. They are a( ommon trouble to residents 
ol subtropical regions. The more usual hmgi are the Aspcr- 
ilillHs nvj_cr rcl iillm^ or one of the mucors. 

CofRSK .\M) SvMi'TuMs.— Til,' diseaM' commences with an 
irritation in tlie ext.'rnal meatus, gradually becoming more 
intense and persistent, and. in occasional cases, a CiTt.-iin 



amount oi eczematous dis( harge is pr(>s(Mit, The I 



learing 



]:.\Ti:h\\AL Mi:.ii cs 



93 



may bocomc affected, and pain is at times complained ot. 
Thi' disease tends to temjiorarv remissions, hut not to sjion- 
taneous cure. On examination of the ear. ])atches are noteil 
in the deejier jKirts of \\\r meatus, citliei of a diity lilack or ot a 
wliite or red colour, actovdinj,' lo tlu' ]iarticul;ir lmi,!;us \v!ii( h 
is |:resem. Tlu--c discolorations may he surrounded h\ 
p;itclies of inflamed lissue. oi he accomiiauifd hy a Iree 
d(--(iu;',niation. whieli. when nniox'fd. will (ittiu ~^llo\v ihe 
h'n;ji!s t(} the u;d<ed i\e. 1 lie liual'e.nd ditlerential diagnosis 



t->-'i- 



# • 






^ 



^ 



-"\v/ 




■.\/ 



Tij 



3 7- 



.\Sl'i:ur,iLI.f 



NK.FR FRT"IT. 



nuist he made hy the aid of thc^ microseop(\ a small portion 
of the f^u'ow'th. remoN'ol eitlur h\' the lorce]is or hy the curette, 
heiuf,^ suhjected to examination. 

Tl{l':.\TMliNT. — The e;ir ■should he well syringed with warm 
lioracic lotion, and ;ni\' \-isihle pat(dies which cannot he so 
remo\-ed cleared awav l>y means of a hlnnt scoo]) or llie 
forcejjs. Alcfiholic ilrops are to he instilled into the e:u- oik e 
or twice daily. The efficacy of a sjiirituous lotion for this jiur- 
iiose is increased if it contain a >mall amount ot caini>hor. 
oil ot cinnamon, oni' part pt r tlu)usanil oi corrosi\i' suhli- 



' n 



M 



94 



!/.l.\ni:ooh- r)/ !)/s/:,!SI-:^ of Tin: l-.lR 



iii.itc. (.!• iivr ],;irts per liundivd of salicylic acid. The (ln)])s 
slioiiid iKil lie conlimicd f,,r ;i ]oni;vi- period than four to six 
Weeks uitli:.ut jiitennission. nor >lionld the\ l)e persisted in 
if tliey canst' nrilation of the canal ; in tiie latter case a iner- 
cnri.d ointnieiu. apjilied in the way jirevionslv des<rilieil. is 
^" 1'^' "SI d nutil all the symptoms of irrii.ition haw dis- 
appeared, or an in-ultlation of ])o\v(h're(l horacic acid may 
he eni|)l()\-e(h 

Herpes of the External Ear and Meatus. 

Herpes, wli, n o( ( nrrint; in tin meatus and whetlier it aftvcts 
the drum or nut. lias very nuich the same (diaracteristics 
as elMwheri a hurnin,!,' sensation followi d h\- ])ain as the 
vesiclts develop. W'lien the -lympanic mendirane is in\-ol\ed, 
]ia.in and deafness suiU'r\-en( . If po>sihle. the vesicles are to 
l)c i.ainted ;i1 their earliest .qiin'ar.incc with a little c')l]odion. 
After the commencement of suppuration, howevei. a soothin,;.; 
ointment ir. ad\isal)le. and aspirin is to hi' adnnnistcred. 

Circumscribed Inflammation of tlie External Meatus ; 
Furunculosis or Abscess.- Ihis kind of ahscess oil. ot 

the e.xiernal meatus i> of the n.ituie of an infectixe inf! 
mation in\-ol\in!,' one of the cerununous {,dands and the si. 
roundiiii,^ lis>ue. and at its earliest stai^'es it does not exceea 
in size that (jf ;; millet -s-ed. 

( -\rs.\Ti(jx. — .\n , xamination oi tiie nnero-or,:,Mnisms fomid 
in the external meatus of apparently healthy peoi)le com- 
monly rewals the presence ol S.'ii Mivlncocciis ci/liiix ov aiiyrif^ , 
and it i> to the entrance of one ot these into the glands 
when tlu' K'lifnd health of th<' ]);itient is somewhat impaired 
that the fnrimciilosis is due. thou,i.,'li it is jirohahle that there 
is frecineiitly m adilition some j.reyious slight inflammation 
ol the canal. ( Kcasionally this ])redisposition is caused hy 
the pres( nee of the as]H'rf,qllus. hy a discharge from the middle 
ear. ov hy the careless use ot eliromic acid or other p.ouertul 
tliera]Ktitic agent. 

CofKSK .\\i) Sv.Mi'T()M,s.~Tlie iirst symptom is that of 
irritation w iiliin the canal, followed hy ;i sliootint: >>y tlir^hhim' 
pain, iiecoming ol a very severe cliaracti'r. keeping the patient 



i:xri:ix\.ii. mi:,i rrs 



95 



awake at ni};ht ami cansint; an ainmint ol conNlituticinal dis- 
tnrl)aiK'i' (-'ntircly out of j)ro|>ortion to tlic sf\iTity ot tlic local 
(li-.fasf. Tlif pain is iiicrcaM il I'V i)rcssurc on the niratus 
and li\- ina>tiration. and {^dandular enlarf^'tnimt may \<c noted 
in front of llie iva^Mis or over the mastoid jironss. 'Ihe jiain 
is lollowrd li\- di>(liarL:e of a small amount of i>us. tliiek in 
eliararicr, w ith iiarti;il lelief of the pain. As one ahscess suii- 
siiles anothir fr-ijuenlK' a))i)ears, and this condition may per- 
sist for se\-eral wieks. 'Ihe temi>erature i> scarcely diAaled 
in adults. ( )c .Monall\- the cd)si-ess. e\-eM after rupture into 
tile lumen of tile canal increases in size and pern, ^ rates Xh'- 
deep tissTies. and, passing outwards Inneath the cartiiaj^'e. 
forms an ahsce.ss over tlie mastoid ])roc(ss thence Inirrowinj^ 
downwards in the direition of the sterno-iiu'stoid musde. nnd 
when tlius ]iresentin,!,' heliind the ]iinna the alis. ess causes 
olijectixe svinj^toms extremely similar to those caused hy a 
suiiperiosteal collection of jnis Anv to acute dise.ise ot tin- 
mastoid ])rocess. The furuiKde is usually situated on the 
upjier or jiostt'rior wall of the canal more rarely on the anterior. 
\\'hen this ahsct ss or furun de is sitn;itid o\er the anterior 
wall, the parotid hnijihatic glands are often in\-ol\-e(l. and 
if the jins jienetrates throu,i;h the deeper tissues- it tonus a 
superlu ial absciss in the parotid let^ion. If the abscess lias 
jienetrated tln' dei'per tissues of tile meatus tlu' canal will l)e 
oc( lud.cd. and jiressure over the external swelliaj,' may cause 
pus at ;i!..es to well out from the canal, thouj^h tins oliserva- 
tion is of no diaj^niostic value. 

Objectivk Symptoms. — W hen furunculosis ot the canal is 
suspccti'd, a lu'eliminarv examination should lie made without 
the nsi' of a s])eculum. so that it the absciss be situated (dose 
to the external meatus, the pain occasioned by the intro- 
duction of a speiulum may be avoided. It howe\er. the 
supjiuratiuf; ]>oint is not \isible. a siieiulum must be intro- 
duced, and with whatever care this may be dc'Ue. a certain 
amount of pam and discomfort is almost unavoidable. On 
inspection it will be observed tlu.t in tlu' canal and its 
external half there is either a distinctly tender sjiot situated 
at a slij:ht depth from the surface, or tlu re m;i.y be onl\- an 



J 'i!»i 



■S 



"v^^Al 



1 : i 



gh 



ii.ixi)!;(h)K 01' Disf.Asrs or rirr. f.au 



III M 



H" 






indefinitely marked diffused swellin,!,'. If the abscess lias 
already ru])tured, there will i)e .i small p(]int irom whieli a 
iiiimiti' (luanl it\- dl [)u> exudes. 

1 Ki-.\r.Mi:N r. — A Iree iiiei^ion carried de( ])1\- thriMiL^h t!ie 
centre (if the ah>cess i> the hot treatment. This should he 
dene it iie-siM,. under the intlueuie ol a ,i;eneral aiuu-t het ic. 
iIkiml;]: the u:^i- dl drax's cdcaini' solnticn ( \|!iii'ndi\-) will 
I" a l.iri^e extent amml the jiain. sliduld (hloruhirm nr 
nitreus oxide !.;a> not he ad\-isahle. Prexaous to imasion. the 
(anal >h(iuld he thdrdu,!j;h!y irrifjated with either a ^trdn^,' 
antiseptic -dlutidu, Mich a> 3 per cent, carholic acid, or with 
perovidi^ d' hydroi^iii Id \-dluin( s. ] he cdiiteiits dl' the ahscess 
(•a\-ity are e\-.i( uated and its walls well ser.iped with a curette, 
and ,1 plu;..; dl t,'auze Sdak((l in 5 p, ceut . carhdhc acid iiscd as 
a lii;ht )ia( kiiif,'. This treatment tends to ]ii\'\-e.it re( urreiice 
"I 'he ai;e(lidn. Th-.' dr(.sMiif;> shduld he chaiii^ed excry 
twi niy-ldur hdurs. the canal hein^ first irri,L;ated with peroxide 
dl hydroi^eii. ,iud alterwards with 3 per cent, carholic acid 
Sdlutidii. Id cdiitrdl the |)ain it is [re(|Uently necessary to 
resort td the i!it(in.il administralidn dt iiKirphia. while. 
accoidiiiL; t.i som,' dhscrxc rs. the teie! y Id ret hirence may 
he paill\ ehi eked hy tile adlll d ddll u\ cahiuiii chldride. 

io.asi' the jMin, it iiu isjou is not nsoit,,! to, hot antisejitic 
haiieiital lolls slidiilil he ..pphtd e\(r\- Idur hours, or aural 
o\-oid.s coiitainin;; opium mav he placed in the mealiis or 
ehloroldiiii \ap(jur hx ally will i;iv( temporary reli( ' (>ec 
Appendix). 

Ulceration of the external Meatus. Superficial ulceiatinn 
ol ihe external meatus tilher lollow ahrasions of coiKhlo- 
mal.i or is a separate scidud.iiy svmptom of s\piiilis. j hr 

>nipld\;i ol lotio ll|;;ra or ( alolllel (hlstlll!.; will he Idlllld 

\el\ , 'll( .|( idUs HI siic h I asi s 

Diphtheritic or Croupoiis Inflammation of the External 
McatUb. I h'' ( All rn.il m. ,itus iua\- he the sr.tt df diphtlu rilie 
inli.immation .md it can usually he traced, lo the , utrincc (.1 
toul w.iter imo ijn- car, as. for instance, ,dler hathiii^' in a 
dirt\ sir, am. Ihe dei pi r paits <;! ihr n'r.ilus rspeciall\- are 
e=- . i: d with a false ni'Mnfmuie i;i a \v!;it; ;:;- vel'wwisli while 



/;.v/7:/V.v.//. .1// I ITS 



97 



hue, wli'cli, when (Irtachrcl from tlu' .^kiii, (.ccasidnally K'avc:. 
.1 raw siirtacc. 

Tkhatmint. — The canal sIkiuM ]n- frci]ucntly irri^at.'il witli 
a soltitidii of ]H'r(lilori<U- ui nuTciiry, i in -'.ood, nr a 2>) ]nT 
itut. S( lution of lacti< acid. Alcohol may be in-tilled into 
III.' c.ir m the iiitcr\-.d> bctwcfU the irri^iatioiis. Tlic external 
meatus is afterwards idu^'i^'ecl with antiseptic ^muzc >()ake(l 
in corrosive sublimate or lactic acid of tlu> above streii^^tli. 

Bony Growths. Boii\- outf,'ro\\tlis in tlie cxti^rnal meatus 
are either diffuse or ( ircum^cribed. 

The Diffused Bony Outgrowths of the External Meatus, or 
the >'.j-called hyperosto-e- consist o: ii more or less annui n" 
outgrowth of bono, which increases gradually and regulnrly 



7? 



a 



L /\ R 



® ® ® ® 



a 



a 



i-i<;. jS.-- iivi'i KosTosi:s .\nii fxostosf.s. 

Limirii "t tlir i;mal. I'li'- two Irlt-liaml liunrc-i arc lu'iHMO.sto.scs 
the luo rif;lit-li.inil iMics cxanipleN of cxnsto-.r-.. 



;uid contracts the meatus e\<'nlually down to an extremelv 
small calibre (Fig. _;S). They are caused either by an irrita- 
tion set \\y bvdischarge or bv some other form ol irritation, 
siu h as a goutv ec/.ema of long standing. The outgrowth 
rarely, if ever, eiitinlv oi > hides tin' i,.nal. Its progress is 
slow, but it is not .n itself a ■ omnion < ausi- ol deatiiess ; for 
where the hvperostosis almo'-t oct hides tin canal ami de.it- 
ness is )iresent- and there is no jii'rforation >A the tvmpanic 
membaiie or discharge from the mii'lle eai. there is iisu.illv 
(din omitant p.Uhological change iii the <leeiier parts. When 
tile hspirostosis is caused by irntatiiiL,' disc h.arges trom the 
middle ear. it iiecomes a matter ol nrL;eni ii. iessit\' that the 
di'-char;;e be eiitirelv and iierm.meiitK- chei ked. or that .i 
radu al ojieratiou lie piiloiiiied ou tl, mastoid Ih lore (cm- 

7 



•■*i 



^ 'i'^ 



98 



IIASDIiOOK 01- DISEASES OE THE EAR 



I 



plcte orclusion of the canal occurs ; for r>li<iul(l ilic .xudation 
be dammed ii] behind bucli an ()!)slructi()n. aLsdrpticin Irnin 
pressure will take jilace. and s. rious secjuel.-e may he with 
certainty exjieoted. either from septic absorption or I m 
extension of the disease to the dee])er ]iarts of the temp. ;al 
hone, and e\-en to the intracranial stnu tures. 

Circumscribed Bony Growths, or Exostoses.- These may be 
com]iact or cancellous, sessile or pedunculated. The spouf^^v 
exostosis is of comparatively rapid ,L,To\vth. is single and 
sessile, and may be situated in any i)art of the meatus, from 
its external orifice to the margins of the niemlirane itself; it 
is covered by a layer of cartilage. The ixory exostosis is 
usually muhii)le. of slow growth, and otcurs in the bony 
me.itus. The S])ongy growth tends to entire occlusion of the 
nuMtus. whilst the sessile ix'ory growths rarely comi)letely 
oblit( rate the canal. 

Symptoms. — The symptoms are those of oci hision <it the 
meatus - that is to say. deafness and noises in the ear. (Jn 
examining the uk atns. in the case of a sessile growth, the canal 
i> tonnd at this part either reduced to a crescent, and the 
growth often is of a pearly, semi-transhicent hue. smaller or 
larger according to the si/e of the growth, or it may be 
com])letely occludi'd by a round tumour of the same colour 
as the re--t ol the meatus. Ii hnwe\-er. the growths are 
multiple, tile canal is then uuire central hour-glass or nnighly 
tietoil in shape, and tliis small passage is r.irely entirely 
obliterated unles> m cons,.(ni('nce df intlammalory compliia- 
tioii or from the ])resen( e ol impai led cerumen or epithelium. 

The rHi:.\TMi:Nr of these growtjis is h.isrd on tile amount 
ol obstfuition they caiise to hearing. Sliould i!i.' it be no 
iiiidille-e;ir dealness. and il wlun tlie obstruciion is ( innj.leli 
there is iki reason to i^rmeed to more radical nie.iMirc s the 
growth m.i\' le remo\-e(i with restoration ol the lie.nin"- 
|iower. As h.is lieeii indicated, however, then i> one m. irked 
exception In the fnfegoing nilv whii h is that npdMtmn shnijld 
invariably he undcrtakiH 'nithoul drhtv in tiiose cases wiier(> 
middle-ear sujipuralion com|ilicatis the ((iiiditioii. and the 
operation siiould then lie th.il known ;is th.j nub. a! jp.'.-.ti.id. 



j-:xri:h'\'.!i. M/:.rrcs 



99 



opt rdtion, not iiitTrly <iii nttt'inpt nKuK' to R'Ntorc tlu' lunu'ii 
of tlic canal. Slioiild {]\r occlusiou hy exostosis he coniplcti'. 
>r almost so. (.'specially it l)otli cars arr affct ted, on" of the 
n-llo\vinp ojH-rations may lie unihrtakcn. It ou^^'lit to I" 
borne in mind, however, that they are t'xtremelj' (lifficult and 
delicate nndertakings. 

Opcyation for Spoui^y Pi'dimciilatrd Grcncths. — Shonld the 
growth be within easy reaeli. one may attem])t to remove 
it from tile Tmatns In' fractnring the liase and twisting the 
growth off liodih' b\- tile aid of a pair of dentist's fang forcejis ; 
a strong wire snare i> sometimes snffieieiit. If tin snrgeon 
jireler. he ma\- cut throngli \\\c pedicle by means of a hne 
( liise] and remo\'e tlie growth by axailsion. Anottier plan is 
lo (hflect the ear lorwards b\- means of a semicircnlar in- 
cision behind the i)inna. and having separated the meatus 
sutticient!\- to expose the growth, it is reinovid after cutting 
through its pedicle with a chisel. Should this method be 
adopted, the external meatus must be candully ])lngged and. 
ke])t jdugged f((r at least ten days after the operation. When 
the growth is removed via the meatus, the same treatment 
is to lie adopted wliich v ill be described as suitable for the 
ixorj- or sessile growth. 

Operation for Ivory (irouihf.— Thv surgeon is here restricted 
to the use of the dental burr, or (diisel. or comjielied to iletlect 
the piinna. In using tiie burr, the object is to remove the 
growth from tlie a]iex towarch ,s base, atteniptnig as f.ir as 
possil)le to nstore the calibre of the meatus to its original size. 
Hurrs ar( to lie iinhritd which have their ext». mities pro- 
tecti'd. Init a sm.ili protector sluudd lie jiassed Inyond he 
growth when the size of the eanal iiernuts. m order to jirolec t 
the drum and middle ear from accidental injury. Ihi^. kind 
ol pmteetion. however, is impossilile ui many ca-es. and the 
oi'erator i> to be guidcil entirelv bv iiis knowledge ol tlie 
anatomy ot the jMrt. He nmsl u>e his uislrunient Iherelore 
Willi lii( L;i('atest (are .tud dexteiit\'. ii the ( hisel is eiii- 
ployi d. there is n<i littt r mstninient th.m the dentist's straight 
enamel i luscl _ Iml ^im e the temper ol ihis instrument is \-ery 

liigii. IT -.ijnuiw i>c UrdWil \'\ in iiif.; in i' i ill iiie iiailieni ,i -.iiiiii- 



11 i 



■.:| 



lIASnf.OOK t)l- DISI-AS'S OF Tlfi: i:.\ii 



i! 



k^\i 



m 



hini|) until tlu' l>l;ulc turns to a lihu' colour wluu coM. Wlun 
usin^' tlic chisel, the j^Towth is attacked near it> oase. and de- 
tuiied in as lar.i^e jie .is possible, thou.^li the niani])ida- 

tion in this, as well all other ojierations. is only learnt 

li\- eNi-.erience. The .an,L;i > which are to he i)orne in mind 
are in|iir\- to llie tvnipanii nienihraiie and ossicles, or di\'ision 
of the facial ner\e. by losing: control of the instrunu'nt at the 
moment of overcoming the resistant e caused hy the growth. 
After the growth has Ixx-u riMiioved to the satisfaction of the 
opi rator. the meatus must lie thoroughly cleansed hy irriga- 
tion willi stroma antiseptics, and an antisejjtic phig inserted, 
and tlie casr Ireatt'd with the strictest antisei^tic jirecautions 
until the healing of the surface is fairly complete. To avoid 
colli raci ion or stenosis ot the mea,tus it is a(l\'isal)le to insert 
a ]( aden tube as largo as the lumen ol the canal will jHrmit, 
ami it is not infreiiuently advantageous to commence the 
insertion of such a tulu' immediately alter the removal of 
the growth. 

Stenosis of the External Meatus may be congenital. po>t- 
operati\e. syphilitic . lraum.it ic, oi ]iost-inflamm;itory. When 
])ost -inflammatory, it is commonly the result of suppurative 
intlanim.it ion of tfie niiddli' e.ir. and will be describi'd as a 
complication of that disease. IMarked contraction frecjuently 
follows chronic eczema, and may be situate at the external 
oiitK (■ or in the cartilaginous parts ; in elderly peojile there is 
olteii noti(rd a tailing in of the cartil.igr le.uling to a partial 
occlusion. 

ri<];.\lMi;NT. — Acquireij webs should be disst'cted away 
by ine.ms of a circular di\-ision of the tissue close to the 
me.it.il \\ ,ill ; a rubber or niet.il tube is then inserted, and 
should be ot as large a size as possilile. 1 his is only removed 
at interxals lor tiie purpose of cleansing the meatus for at 
le.ist hilir to six weeks ; nor should tiie ( .ise then be .dlo'.ved 
to |i.lss \\{>\\\ obM-rwition but should be seen from time to 
time tor another two months, in (;rder to <lieck any tendency 
to recurrence that in.iy siiow itsell. Partial occlusion usually 

|)eIIMlts ot dllit.ltloll ii\- me. ins ot rubber tuiies. Siiould the 
i uineii lie loo sin.iii. di\isioii oi tiie tissues iroiii tiu' lenire out- 



EXTERSAL MEATUS 



loi 



'* i 



wards will enable the surgeon to insert a tube. For eollapse 
(if the meatus or eontraetion at its orifiee small dilators 
ean be obtained at the instrument-makers, and are to l)e 
eonstantlj' worn. Most congenital occlusions are osseous. :ind 
ino])eral)!e. 

Keratosis Obturans, or the Formation of Epithelial Plugs 
in the External Meatus. This is a eonditiou which occm-s 
more frequentlv altt'r middle age. and is due to an excessi\-e 
easting otf of e[)itheliuin within the deeper jiarts of tiie meatus 
and to its retention within it. If the disease has existed tor 
a considerable tinu-. thi' meatus is uuicli distended in its inner- 
most extremity- and the plug firmly adlu'rent. or so lightly 
lixeil that the line of demarcation lietween tlie dr;id anil li\-ing 
iliithelium is nctt clearly \isil)le. and irritation is thus set up. 
'I his irritation increases the injurious I'ffec* of the jjressure 
exercised by the plug, wliicii is in i*s outer j'.irt loniu'd of 
cerumen. 

The (liief symptom is that of deafness, accomjianied 
occasionally liy m'uralgia oi various parts of the liead and 
considerable mental disturbance, esju'ciallv in neurotic suli- 
jects in whnin a condition allied to ir.elancholia sometimes 
di'N'elops. 

Tkli.viMK.N r. — First of all, an .itteir])t is made to remove 
the mass I 'V means ol the syringe ; but should this hiil a> it 
frecjuentiy does, an indeaxour may be made to si'parate the 
edge of tlu- mass from the lUeatal wall by means of a proi)e. 
and llieii direct tiie -tream o! water from the sNringc inin the 
elelt tiiu^ lornied. and sn liy means ot c;> d tcf^o expel the 
di'l)iiN. Can must l)e exercised e\'en liy praciitioiiers well 
skilleel ii: the use of amal instruments in any attempt m.ide to 
extrait the mass liy means ol loicejis or other instruments, 
more esjic eially in elderly iie(ii>ie. suk c ji.iin and e\-en ruptuie 
ol the memlir.ina t\iiipani. whuli is .it times attached to .md 
!-■ alv>ays much '.Neakeiied by the pressure of, the ]ilug, iii ty be 
lailsed. It is lieltel" to pl(ie<-ed mine slowly, .md to .ltt( lllpt 
t(i s(ill(ii tlie mass liy ine.uis <il (uie ol tiie gult.u or ji.istes 



'i 1 



1 1 



;., „ 1. .. .1;. 



the ear at niglit. .md isery second or third day il will i'c 



T02 



HAXDBOOK OF DISEASES OF THE EAR 









possible to remove with the syringe some portion until the 
whole meatus is ekar. 

As suhsecnicnl treatment t'rictinn> df tlie iiicatus with oxide 
ol mereui\- ointment, as will l>e lU'serihed under the treatment 
of eerummous im])aeti(in, may he ad.optetl ; the meatus should 
he ins])eeted e\'ery six months, opeeially wliere iliere is mueli 
dilation ot the eanal. 



DISEASES OF THE CERUMINOUS GLANDS 

Diminished Secretion. When tlie -eeretion irom the eeni- 
miiKius 1,'lanil^ is nuieh diminished or entirely ahsent , tlie 
external meatus het'omes \-er\' dr\-, and stales ot cast-off 
e])itheliuni aie lound within its hmien. whuh generally ai)i)ears 
wider than norm.d on aecount of a eertain amount of atrophy 
ha\'in,L; ta.ken place in its hnini; luemiirane. 

'1 lu'se jiatieiUs comi)lain .i^eneralle ol a large amount of 
irritation in tlie external me.itus, and at the same time not 
infrequentl\- ut suhjectiw noises within the ear. in which case 
the deliciency ol Secretion will he secondary to, and p>art of. 
a chronic disease ot the middle ear. 

rKi;.\iMt:N 1. -The drw sc tl\' condition of the external 
meatus is liest tieated |]\- gentle frictions with a httle cotton- 
wodl twisted round .1 \s(](*den or \ulcanite ]iro|ie. and hihri- 
I'ati d with dilute ammnniated nienury ointment. 

Excess of Secretion, l^xccssiee ^.ecretion of ((Uinien is 
(hie t(i a dise,(s>(l (diidiiion ot the ceiiiminous glands, ami is 
closeK' idiied ill cli.iraiter to a selxiiaho.i. 1 he nature of 
the eciumeii is altered and its (juantity inarkeilly increased. 
It contains less moisture, and tends to accumulate within the- 
me iliis, I'xith ears aie usuall\- alfi'cted. hut one is. as a rule, 
more i)lo(l<.cd, than the other. When this ainimulatioii of 
w.ix oc( urs in i hildreii. adenoid vegetat ions are usuallv present 
in the naso-pliarynx ; when |)resent in adults it is generally 
acc(ini|i,mied l>y some hirni ot nasal stenosis ami ( hiniiic n;iso- 
]iharvngitis. Such lacts le.id to the liehef thut the iiureased 
.Mii\ii\ iii iiii .i;ian(is is eiihii (iiie lo an I'Xteiision of iii- 
llamniaiKin lioiii the iiaso-ph,(r\n\ \ ia the I'lustachian tui)e 



DISEASES OF THE CERU.'.'IXOUS GLANDS 



103 



i 



and middle car to the external ineatns. or to a reflex irritation 
caused by nasal or post-nasal irritation. The ccruminous 
secretion is mixed with dust, epithelium, and hairs ; it fi;radu- 
ally loses moisture, and thus becomes darker in colour and 
Ann or liard in character. 

Symptoms. — -The constant symptoms of impacted cerumen 
are deafness, with or without subjective noises, and auto- 
]ihonia. whilst neura]j.^ic pains over the side of the head 
may be induced ; irrital.nn of a l)ranch of the jmeunio^astric 
supplied to the skin of the meatus may cause a trout>!.some 
cough. The deafness is usually sudden and complete, and can 
frequently be traced to the entrance of a small ;imount of 
water into the external meatus, thence between tlu ccru- 
minous plug and the meatal wall ; the (hnifness is (hu' to the 
water stojjping up this crevice, througli which the sound- 
wavt> find their wuv. and later bv causing the ccruminous 
plug to swell by iml)ibition. thus completidy occluding the 
meatus. 

TKiiAiMKNT. — Tbe treatment consists primarily in removing 
the impacted cerunu-n. and secondarily in attempting to pre- 
vent its recurrence. 

To remove the impaction recourse is had to the syringe, and 
it umst be borne in mind that so long as the stream of water 
is dircctrd along t!ie po.sterior or su])<rior walls of the canal, 
the amount of force used may. and should be consideral)le. 
Under no circumstances whatever must the stream of water 
!>(• direited against the plug itself, for tliis would only drive 
it fun' T into the meatus, or, sliould it have been remo\'e<l, 
tile St. earn 01 water would thus strike fully on the membrane, 
and c(insider.d)le damage may he done. The temperature of 
the w.iter >hiadd be at aliout ()t)° to loo^ Fahr. 

It heiiueiitlv liappens lither that it is imjios'-ible to remove 
the plug at the I'u^t syringing or tliat its deepei portions can- 
not lie e\a(iuite(!. It tlieii becomes necessary to .ido])t some 
means to soften tin wax. One of the gutt;e gi\in in the 
.\p|>iiidix (21. 22) mav bi' prescrilii '1. and a te.ispoonful of 
tlie warmed lotion instilled into tlie ear shortly belore retiring 
to rest, the i^atient lieing directed to sleep lying on the opposite 



,3 I 

n I 
■I i 



hrM 



104 



ir.txnnonK or Disi-Asr.s or riir r.ir 



lt ijlj { 


1 



side. liaviiiL,' li,i;litlv ]>;i('ki'(l tlic affrctcd car with rdttoii-wnol. 
'1 licsc (li'dps slioulil l)c I'ljuaU'd <in two or tlu't-c succcssix'c 
cNcniiif^s. wlicii tlif mass will he soltciiti!. and is readily dis- 
intc.i^ratt'd and rcinoxTd \>y tlie syrinj^'t'. No instrunn'iits are 
to be eni]ilo\-ed ill VelHoxini;" tlloe mIu'^s unless the snr^eon 
has had nnn h e\]Hi-ienee in their 1 >e. :i^ it is very ea>y lor 
unskilled h.ind> to eau^e irrejiarahl' daniai^e 1)\- iniHnn,^ the 
ineinhrana txinpaiii and the eonlent^ ol the tynipanuni. 

Alter till' i'ein<i\al ol .ill the ecrunu n the meatus >honld he 
cart'hdh' dried.and.il possible, no Imther invent i,uat ion ol the 
jKitieiit tor deaines> carried out imtil the eliects ol the :-y/in,L;in ; 
ha\-e p;i>-M(l oil' a> all the ti^-iies will be soniewluit eni;or.L;"d 
with 111 ■ Mid ,11 id the cnrvatui'e o! the nieinbi';nie ha> olteii iiet n 

allei ted b\- the pl'i^^Ule ol the jilus;. 

I he lie.itnient toward^ prexfiition ol ii ( urreiiee ol the 
trouble i> ba'-id on the a^>uni| ii ion ih;it this conduion i> due 
to a di-eiixij (onditioii o| tht inlands. ,ind -o the remedies 
niu^i 111' diieeted towards restoring; tluni to a health\- con- 
dition. 'Ihr tollowin;,; method will L;i\e \-er\- L;(Hid results ■ 

'I he p.itient imisl be supplit<l with a small wooden "r 
\ulcanite probe and diri'( ii d to wiap round one en<l of this 
a layer ol cotton-wool, beiiii,' cnrelul that the wixil piojects 
Well lie\ond ihi' piobe. He should then take on his lore- 
linger a small amount ol yellow o.xide ol inereur\- ointment. 
S ,ui'.iins to the ouiue ol \aseline and j^eiit ly smear this on 
the mop. takim; tare that there is no excess 01 (untment 
upon It. Willi a mop so prepared, identic Irution is ap]ilied 
lo the ( Ml inal imalns o\(i its !uitei ,' uii h om e or twice 
weekl\-. I'oo mill h stress ( annot be l.iid on tin impoi t.iiice 
(A ]>arsimouions iise ol the medic, imeiit olherwiM- patients 
ma\ coinpli '( ly iill their e.ns with oiiitiiieiil. 



NEW GROWTHS 

Papilloniata are occiisinn.diy found at the eiitraucc ol the 
canal, and sIkhiM be 11 moved with .1 si .dju 1. the base beiiiL; 
cauteii/,1 d. 

Maiigiiant Disease < (imiiii ncm^ in the (\tenal ni'ttis is 



XEW GROWTHS 105 

relatively rare. When epitluliomata occurs it is usvially 
acconii)anu'd liv Rrcat iiain. not limited to the part involved, 
Init radial in;,' over a lart^e jiortion of the head and neck. 
An early synijitoin of tliis ,L,To\vth of the exterital nieattis is 
fixation of the atuacle. Thei\> is a tliin offensive^ sanions dis- 







IK.. i'J. 



-S.\KlOM.\ OF TI.MI'OKAI. HONE, 



char^'e 



deafness is net a net essary residt. inih'ss the growth 
funt^ates and occludes tlie nie.itus. On exaniin.ation there is 
seen a r,i,i^L;ed ulcer, with pilid uj) am' lliit kened ed^;es, wliicli 
lile.d re.idily when toiulied witli a jinihe. Tlie -lands in 
the u)i|nT i)art (il the neck are soon involved, and it ( imld (inly 
he m very early cas--s tiiat tiie smi^eou would iie iiisiilieil 
in attenijitin;^ to ixtirpate the growth. 11 it should he 



f iki 






> i I 




lo6 



H.i.,DnOOK or DISEASES OF THE EAR 



attempted, the operator must l)e prepared to carry out a 
di'ej), rlifticnlt dissection of the temporal lione. 

Sarcomata and adeno-sarcomata may arise in this situation, 
and since tliey both ti-nd to recur, they are to he freely ren-.oved 
if seen early. 



FOREIGN BODIES IN THE EXTERNAL MEATUS 

These are usually met with in children, or, in the case of 
adults, they haye he( n inserted into th(> ear in childhood and 
their presence forj^'otten : they are then usually inanimate. 
Occasionally an adtdt will ' |)ick ' his ears with a pin. whicli 
slijjs out of Ids hngers and drops into the ileei)er jmrts of the 
meatus. With these exceptions, foreign hodies in aduUs are 
usually of organized structure, such as polyp- md necrosed 
hone, which are pro])erly considered under the .-(.mplications 
of suppuratiye otitis media. When a patient is brought with 
the statement that a fori'ign body is in the ear. it is a truism, 
but necessary to say. that, as far as possil)le. the practitioner 
should make certain that the foreign body is present before 
attempting its remoyal. He must remember that the extreme 
inner jiart of the floor of the meatus, as well as the lowest 
part of the dram, are fre(juently in\-isible. on account of the 
natural depression in the floor of the meatus at its inner part. 
Hence, if the sensation of the foreign body exists, no liarm 
can lie done in carefully syringing out the meatus. 

Before proceeding, howeyer. to the question of instru- 
mental treatment, it is well to remember that eyen syringing 
for the remoyal of (-ertain for'Mgn bodies should not lie 
attempted unless the surgeon is ready and able to take 
other measures. Vegetable seeds, if not remoyal)le by 
syringing. ind)i])e water and increase in size, often with 
disastrous consequences if ojieratiye measures are not quickly 
taken. 

Foreign Ixidiis in the external auditory nteatus nuiy he 
remoyed either by syringing or by the use of instruments, 
sudi as iiooi<s ;ind forceps. In a certain numl)er ot cases 
where neither of these methods ayail, and where on account 



FOREIGN BODIES IX THE EXTERNAL ME AT IS 107 

of swelling of the canal a severer complication threatens, it 
may be necessary to extract them l)y operative means. 

Whichever method is adopted, the following precautions 
shoidd he observed : (i) As the patients are usually children, 
with whom, unless exceptionally tractable, it is im])ossil)lo to 
avoid damage to the imporcant structun the surgeon must 
have the helj) of a general anaesthetic. {2} it is essential that 
good light is available, and all manijnilations are carried out 
with its aid. If the foreign liody is one which piesents a 
surface easily grasped by forceps or a hook, or if it is j)ossible 
to jiass a hook or hne bent prol)(> lieyond it. then nothing more 
rcciuires to be done. If the substance is smooth and the 
surgeon cannot pass an instrument bi'yond it. syringing will 
in most cases prove more eificacious. A small crevice usually 
exists between the foreign body and the meatus. This slundd 
be the side of the meatus along which the stream of water is 
driven, and particular care must be taken that, as far as pos- 
sil)le. the ()l)ject itself does not receive the full force of the 
stream of waxer. 

Other methods of removing the foreign body, as by means of 
suction, may be considered. One of the most useful is by 
means of a line indiarul)l)er tuiw drawn over the nozzle of a 
large rublier sj-ring.' or Politzer's bag. which is exhausted, and 
the moistened end of the tube pushed gently but tirmly against 
the foreign body, whilst the bag is allowed to expand and 
sufficient suction is sometimes obtained to withdraw the 
offending object. A tine ])iece of thread may be sometimes 
attached liy means of glue or a quickly drying cement to the 
foreign body, and it may be withdrawn when the adhesive 
material has had time to set. A thin wire loop may occa- 
sionally be passed beyond and around the object. It may be 
advisable, when the foreign body is one which will swell by 
the imbil)ition of water, to syringe with oil. But whichever 
operation is resolved upon, it should alwaj-s be borne in mind 
that unless the objt'ct has been introduced into an ear already 
the seat of sui>imration. it may remain for a long time without 
causmg any disturbance. 

If an insect find its way into the external meatus it can 



I ! 



ffli' 



lOS 



IIAXDIiUOK OF DISEASICS OF THE EAR 



always l)e destroyed by chloroform vajwur. and may then 
easily be syrinj^'ed out. I'illinf,' the meatus with oil brings 
the int ruder wit bin reach of easy rein<)\'.d. 

When trom one cause or another the foreign bo<ly has set 
np sueli ;in inilanimatory disturl ance that the meatus is 
completely occhuU'd. and it is im])ossil)le to reuKJve it in any 
one or other ot tlie aboN'c ways, the ear should be reflected 
forwards l)y ineaus of an incision close behind the auricle ; 
the eartila,L;inous meatus is gently separated from the bony 
j)osterior wall, .md then di\-ided longitudinallv sutficientlv 
far baidv to enable the surgeon to le\er out the object l)y 
means of a [\\\c instrununt passi'd beyond it. If this step 
should prove necessary the post->iural incision is to be care- 
fully closed, and the external meatus thoroughly washed out 
and i)]ugged with gauze under strictly antisejjtic precautions. 
If tliere is no discharge a plug may remain in situ from ten to 
fourteen days, in order to thoroughly re-establish the patency 
of the canal. 



RUPTURE OF THE MEMBRANA TYMPANI 

This lesiciu lias already been alludetl to on ]). 2,;. as far as 
its causation is concerned. It is only necessary to add here 
that when the membrane i> ruptmvd as the effect of loud 
explosions, it will be found that in every case the mi'mbrana 
tymi)ani is parallel to the external surface of the skidl tliat it 
d(Hs not a|)j)i'ar to lie obli{]uely. and that the meatus is wide 
and straight, these conditi(jns allowing the force of th" ex- 
plosion to im]>ingi' dirt'Ctly on the membrane. 

Sv.Mi'TOMs.— Deafness, tinnitus, giddiness, slight dis( barge 
of f)lood. m many cases followed by purulent discharge. ( )n 
examination a rujiture will be found in the drum, usually 
in tlu' lower segment when it is the eftect of a lilow or 
cxjdosion. and a \-ertical tear wlien the base of I he .-^kull is 
fractured. 

'1 Ki:.\TMi:xT. — The external meatus and drum are to be 

'.. L-.: -.-i i;;;jy v ;e,;:;:.e; i w ;i;; a;: *;ii; l^^cp-iic I^C'illiiOit — rjriler.ii ti V 

I m 5.000 Spirituous biniodide of mercury solution. A little 



IWil 



uri'iria: oi- rut: .1// m//;A'.;.v.( / v.i//'./.\/ 



ii)() 



ioddfonn should tlicn lu' Mown in. and tin- rxtiinal nu-.itu> 
lif^htly jiacki'd with sttrili/.cd i^au/i'. 

An altc- .alive tiTatnu'nt is to pass a small p'ww of f^'laztd 
paper, moistened with an antisej^tie or collodion, over the 
]nrforation. The pajicr adheres, and the membranes usually 
heal in a h-w days. The same li};ht antiseptic f^auzc i)aekini,' 
is employed as when no paper is '.ised. II sui)pu'.ation has 
occurred, the treatment suggested for that condition is to be 
employed 



H 






( jiapti:r VII 

EUSTACHIAN TUBE OBSTRUCTION 



!li! 



Obstructiox (if the Eustachian tul)c. of an arntc or rlironic 
nature, without material involvement of the middle <>ar. is a 
by no means nifn-quent cause of deafness. In boih varieties 
the origin of the imjiaired p.itency of the tulie i^ either occlu- 
sion .It the orifici more or le>s complete, from adenoid vege- 
tations in the naso-pharynx, or from inflammatory swelling 
of its lining niemlnane. conse(]uent upon an extension of 
inilaiiimation from one >truetur<' or another in the naso- 
j)harynx. In the acute cases the mucous memlirane and sub- 
mucosa of the tube are infiltrated with small cells and serum. 
In the chronic cases the small-celled infiltration has liecomc 
oiganized. and a fil)rous ^^tricture remains. When the ob- 
struction is intratubal. the site of contraction is rarely at the 
orifice. ev(>n in the acute cases, but is usually found at the 
ont( r extremity of the cartilaginous tulie, at its junction with 
the osseous ju>rt ion. 

Acute Eustachian Obstruction. The syiu])toms are dis- 
tinctive. Alter a ^light > oM the patient notices sudden 
deafness, wliich is UMially unilateral. He may complain ol 
a freling also of minibnes> witli fulness in the atficted rar. 
and will II till' lie.iring returns its rcNtoratinn is preceded liv a 
pop in the t ai . 

OiijlOiTivi' Sk.n When ilie tymi'aiiic membrane is 
( xamiiuil. tile (one ol light is usually tonnd sbghtlv higher 
than 11(11 m,d. and incomplete at its outer extremity. The 
liaiiill- of tin malleus will lie sli^litlv injd t(d. an.l tiie lining 
iiiiiiiliiaiie ol tiir niiiei w.dl ('• liie lyiiipaiiic ca\'it\' is com- 
monly seen lliioMf^h t!ie drum as a liul! n il letlex. The 



Ilo 



1.1 
I!'! 



EUSTACHIAN TUBF. OliSTRUCTlOX 



III 



more pronounced, would have caused serous effusion into tlic 
tympanum. This form of ol«truction is apt to recur at in- 
tervals, and then, like recurrent serous catarrh, tends to 
Itroduce an adhesive otitis media, or to obliterate nii)n> or 
less completely the Eustachian tube, merging into a clironic 
condition. The patient is often markedly deaf, with tinnitus 
and will have a slight + or not unfrequently a - l)one- 
conduetion with a negative Rinn( . if tlie lione-conductifin is 
diminished, it will l)e restored after inflation. 

Treatment.~As in most acute inflammatory conditions, 
a l)risk mercurial i)urge is valuable ; a sechitive vapour, such 
as that from the conijiound tincture of benzoin, is also very 
heljiful. the ])atient inhaling and exhaling tht> vajiour through 
tlie nose. This inhalation sixiuld l)e repieated at inter\-als of 
four hours during the day. and the jiatient is l)etter conlmtnl 
to the house. At the expiration of a few days, when the 
jKitenc-y of the Eustiuhian tnl)e is usually rt>-estal)lishe(l, 
inflation of the middle ear should be employed bi-weekly for 
a tew weeks, even though the hearing is entirely restored ; 
for by this means subsequent attacks will cause less injury to 
the intratym])anic structures, as the tendon of the tensor 
tymjiani will thus have been prevented from undergoing con- 
traction. If the i)atency of the Eustachian tube is not 
restored, an Eustachian liougie should be emjiloyt d a few- 
times. At the same time a very cu'eful examination of tlie 
nose and naso-pharynx shoidd be made, and as far as pos>il)le 
■ I projiliylactic treatment adopted i.e.. one winch aims 
primarily at obtaining a free air-w;iy in the infeiioi 'ueatus. 

'1 be presence of adenoid vegetations in the naso-pharynx. 
il ihe growtli inteiferes mechanically with the normal oiHiiing 
of the tube, will cause >vmptoins of obstruction, nsuallv of 
a ehioiiic ( haiat tei : but if tlie f.;rowtli is rr.iiid. comparatively 
sudden de.ltliess will i le produced. 

Chroni". Obstruction. - ( lnoni-- obstruction of the Eustai hian 

lube i^ ;\ Yfyy livcjuiiit forcruuner and < oiu omitaiit ot Mie 

adllesi\-e for, 11 ol I hionir middle-ear disease, ,llld its l)resenee 
materially contributes to tln' extreme r 'tract lou of the diuni 

.fell !!! s< >!>!e i if * b: ■',;■ i :;■,:■■_ !:: *:;•* -;:-.. .-^ *:-.-:-....;. ,i ... ; i" 

tile iiunibiaiie is tin duel sign ot an old-atanduig contraction 



tu 



112 



lIASniiOOK OF DISEASES OE Till: EAR 



of Ibf Kiista:hian tuln" ; in a certain inoixntion of casi-s of 
cluunic middle-ear disease. \hv strieture of the tube forms the 
most imi>()rtant jiart of \\\v disiase. and when the jiateiicy of 
the ranal is restored a great improvement in hearing k ahnost 
immediately noticed. Tinnitus is again a common syni})Iom. 

Di.xc.NOSis. — In all forms of tubal obstruction a diagnosis 
is n.iade partly from the api)earance of the drum. Imt prin- 
ci])ally from the sound olitained by using the Eustachian 
catheter ; when the tnl)e is obstructed tiie sound is snuiU, 
distant, and sil>ilant ; whilst, with a free tube, as has been 
menti(med. the sound is full and near. 

At times the cartilaginous end of tlie tube is chronically 
enlarged. When lioth are afffctcd th.y may almost meet 
in the miihlle line. Polyi»i have been sei'U m the entrance of 
the lube. 

Tklatmknt. — The treatment which yields the most satis- 
btctory result is the regular use of the Mustachian bougie. 
The-..- are made of gum elastic or celluloid, and may In- jKissetl. 
two tu tlu'ce tinu'S a week until the tid'c remanis free. (The 
use ol the linugie is described on p. 74.) The bougie should 
Ik- left m silu fur from two to five minutts. and it is always 
advisalile to juus the largest si/,.' iiossilile. Besides the use 
of flexible boueics the practitioner may employ electrolysis. 
Tlie rxlernal mrat\is is Idled wilh water, and the negative 
jiole placed withm tlie meatus, while tlie positive [lole is c (.ii 
n.ected witii a lUK \ul(.inite luiugie tii>iied with m. ' d. The 
current mu>t be turned on viiv graduall\ and not kei>t on 
lor more than ihii-e minuter at a ti.iie ; care \\\n>\ in exercisi'd 
in lucaking the flow ot tlie unrent since vapidly disconnecting 
the jioles is apt to cause a severe \-ertigo. '1 he most suitable 
stiength of the current is aliout 5 milliamperes. As an 
adjunct to this mode ol treatment the iiaMei.harynx slioultl 
be painti'd .ilter each sitting wilh Mandl > weak -nhition 
(A]ipen<lix .'/i). 

Oiher dise,is<s of the ]-"iistacliian tube wliicli d.eserve a 
passing nienl!e>n are uKcrat 1011 of tli(> tulw or KdMiimiUler's 
fossa. Mther syiihilitn- or lubenular. they require tlu usual 
and gelieiai iieaijiuin liviojiiCiI U)r lacije ll;:;;;;;:- :;. ::: •.••.;:■-: 
jjarts ol the body. 






CHAPTER VIII 
ACUTE DISEASES OF THE MIDDLE EAR 

Acute Inflammation of the Middle Ear— Acute Otitis Media. 

AciTi- intlaiiiiiKilion of tlie tympanic cavity is the result of 
an infection which may reach it either liy way of the Eus- 
tachian tube, the blood-stream, or tlic lymphatics of the part. 

Tlie jKirt jilayed liy an inflammation of the naso-pharyngeal 
muco.-a in the production of acute otitis media is a very large 
one. In fact, it is doubtful whether, apart from tul)ercle. 
any cases of acute middle-ear infection occur in which an in- 
flameil state of tlie naso-pharyngeal mucosa is not already 
existing. 

The i)rincipal cause is undoubtedly the direct extension 
of intl.immation of the Eustacliian tube from the naso- 
pharynx ; sometmies this is the sole cause, at others the 
primary. 

Otitis media i> a frecjuent com])lication cf thi various 
exanthemata and of acute infectious disorders. Forenu)st 
amongst thoe are scarlet fever. nu'iLsles. diphtheria, whooping- 
( ougli. .md typh'ijd fever. It .dso occurs secontlarily to any 
nasd-pharyngeal inllammation. more esixcially that accom- 
panying the general symptoms of iidluenza. and it is at the 
sami time one oi the most serious complic.ition;> of bronchitis 
and ( .1) Hilary bronchitis in children. Patients with obstrui five 
n,i>al disease (ir those suffering from hypertrophic disease of 
tlir naso-pliaryngeal tonsil are esincially liable to aiute m- 
li.iininalion of tlie middle e.ir. 

No nioic fruitful cause ^n .u tite middle-e.u- infection exists 
tli.ui tlie tt.u ible projection of septic material into the middh' 
> .11 uiii ii IS Ml iutjiieiiiiy iiie iiMiit oi too deiuiiiinrd ellort 






Il i 



!1 



"4 



n.ixDuooK OF nisi:Asr.s or nii: ear 



;it dialing tin- nose liy Mowing wlirn tlie patient is suffering 
Iroin acute nasal catarrh. Nor nuist the occasional ill-effect 
of the nasal douche lie forgotten, for if too great force l)e used 
infective matter may I'e forced by the stream of fluid up the 
Eustacliian tube into the middle ear. 

r.\Tii()i,()(;v. — Tlie intl.imniatory changes which have their 
start ing-jMiint in the na^o-]>liarynx cause engorgement of the 
lining mendirant- both of the luistachian tulie and of the 
ca\uni tym])ani ; the whole of this swollen nmcosa is inlil- 
t rated with leucocytes. The tympanic cavity then liecomes 
more or less lillcd with imico-si'rous t'xudation. in which is 
found a \-arial>le number of micro-organiMiis mixed with 
leucocvte> lilii'iati'tl from the lining menil)rane of the tym- 
panum, the attic, and the antrum. The meml)rana tympani 
itself is involved in the s])ri'ad of the general inflammation, 
and a further extension of intlammation not infrecjuently 
proct'eds along the ixtirnal nitatus. by which its -^olt tissues 
are swollen, wit^li ])arlial occlusion of its lumen , serous or 
sanious lmll;e are sometimes formed on the meatal walls, and 
are fulloweil. alter tlie alijiorption or removal of tin ir contents, 
liy d.c^(|u. im.it ion. In f.ut. in tliis discusc it is not an in- 
irecjuent experience- to ol)tain an almost comiilete epithelial 
cast of till' external nuatus. 

S^ .Mi'ioMS. — Pain i^ tlie prominent s\inptom. and in char- 
acter it may Ite paioxvsmal or continuous. Patients refiT 
it usually to the ear Imt fre(iuently it radiates over the 
alte( ted sidi' of tile head. The pain is iiu ri'ased by pressure 
on tlie tragus, and otteii !>y :iioveiiient of the jaw. It is 
worse at iiiglit. and accompanu'd liy a rel,iti\-ely liigh teiii- 
l>eiatuve- from loi^ to 105" V A slight rigor is not iiitrc- 
queiitiy experienced in the early stai^o ol miK (»-puruleiit 
cases. A sense ol tuliiess ill till e.ir. autoplioiiia. and ih'ainess 
arc as (oiistant as jiaiii. In i hildreii theie may lie deiiiium 
and coiiNuIsioiis ; in veiy '■luiig p.ilieiits it will often be 
noticed liiat liie infant is Kiiitinuallv putting tiie hand to ilu- 
alleited eai . ol tliat Ik piiltls to lie on tile otiui side, .llld 
al\\a\s s(ieaiiis w hi 11 ibe e.u i-. tmulieil by tlie inotber or 
imiM'. 



ACUTE DISr.ASr.S OF THE MIDDLE EAR 



Incessant crying in children, not obviously abdominal in 
origin, should always direct the practitioner's attention to the 
sufferer's ears. As has already been mentioned, the skin 
of the external meatus is sometimes involved, and that even 
in the early stages of the disease. If so. its innermost part, 
if visible, is red and swollen, and bull?e (Plate I.- Fig. 12), 
containing either clear or sanious fluid, are occasionally 
noticed in this situation. The swelling of the meatus may be 
so great as to render imjiossible all insj)ection of the meinbrana 
tvmpani. It is in the memlirana tympani itself, however, 
that the most characteristic changes are noticed. In the 
earliest stages of inflammation there is seen on the handle of 
the mall' us a dilatation of its vessels, and on careful inspection 
a leasli of \-essels will be observed ruiming from the posterior 
superior ])art of the periphery down to the handle of the 
malleus, near the short ])rocess (Plate I.). No further exten- 
sion of the inflammatory process may occur, and tb.e attack 
will tlien end in resolution. In tlie next stage the liandle of 
thi' malleus becomes uniformly red. and small radiating vessels 
mav be noted on the drum itself, tiie short process not altering 
in colour (Plate 1.). As the inflammatory process develops 
the liandle of the malleus loses its sharj)ly-ih lined border, and 
i» sembles in shajie the finger of a glove, and in coh)ur changes 
to a l)right red liue. It is at this stage that the e])itlieli.i' 
covering of the sliort jMOcess Ix^comes inx'olved in the gene al 
inflammatory state, whil.-^t the meml)rane as a whole gr.idually 
becomes ])ink. and the vessels radiating; from the handle of 
tlie malleus more numerous and more dilated. Tlie cone of 
light disapjiears. .md the nuinbr.ine iiecomes lustreless. From 
]iink the membrane changes to red, and the ])osteriur half 
bulges outw.irds. hiding the anterior portion. At this stage 
it is impossible to distinguish the outline of the malleus or the 
edge of the 1\ni|)aiii( iiieiiibi .iiie. for the adj.iceiit p.irts oi 
the meatus are probably also inflamed. Should the disease 
tend towards i- si hition. all Hie al" M-mentione<l <h.uiges will 
take place in inverse ord<r. with the exci piion that, as the 
nieiiiiiiane recovers its iioiiiial t'olour and cinwiture. stri.e 
r. idi.it 111(4 tioiii the malleus will become vi.>-ilile on its -uilace 



k: 



Ii6 



IIASDBOOK OF DISF.ASES OF THE EAR 



(Plate I.. Fig. 3). These are the ii'sult of the distension of 
tile tympanic membrane, and are due to rela.xation of its 
libres when tlu' distentling foree is removed ; they disappear 
in the ( otnse of a few days, anil have no signilicance. wliilst 
the membrane gradually becomes again lustrous, and the cone 
of light rea])pears. Should su})iiuration occtu'. the drum 
will be perforated, and the pus will show itself, if in sufficient 
(luantity. in the e.xlernal meatus. Discharge from the canal 
in these cases may be almost clear or saniotis at its comnunce- 
nii'iil. but in either v\vn\. it will graduallv become j>uruk'nt. 
and is very often ropy in character. This mucoid discharge is 
con>ideri(l to l)e e.xuded from tlie Eustachian tube. When 
the intlammation is severe and secondary to one of the 
ex.uithemata. tlu' piiforation may i>e of great extent and 
spread rapidly. The major part of the drum in such an event 
may be destroyed, and partial necrosis of the ossicles is a 
frecjueiit c()ni])lication The whoU' membrane is sometimes 
destroyed m the course of a lew days. When, however, the 
inihimm.itory jiroducts become localized a;.d con lined either 
to the attic or posterior su]H'ri()r (juadrant. tlie practitioner 
will jH'iceive on examination of the ear that instead of the 
bright red uniform swelling as al)ovi' described, tiiere Ls u 
bright led pouch resembling .1 jiolypus hanging eitlu'r over 
the malK'us or beiiind it In the former instance it is a 
bulging of Shrapneil's nu'iubrane ; in the latter, a bulging of 
the posterior superior (juadrant of the membrane (Plate I , 
Fig. 4). Oni' m.iy be able to di te( 1 a Muall granulation near 
Iheajiexof liie swelling. Tlu^siiot is t he Sit c of t he jierfora- 
tion of the pouch, and horn its lesemblaiKc lo a polypus a 
mistaken diagnosis may be made. Wiuii a peilor.it ion takes 
place in the anterior segment ol the memlu.uie it is more 
dift'icull t<i det( ( t than one situated m the posterior jioi tion. 

(lemmie polypus loiination. excn ir. ai ute cases, however. 
(Kiuis. the jiolypus ^piinj^iiif; Iroiii an ulcer in lli^- mucosa of 
the inner lyniiianic wall at th'sanie lr\(! as the jiei loration. 

( )ne <(>n(htion which is occasionally mistaken lor ai uti' 
(Kills media Is ,111 ,i( lite intbininiat ion of .i Ivmphatic u.land 
]\iiig jUst beneath the stei 110-iiiastoid iiiusv Ir. This ( auses 



ACUTE nrsnAsr:s ni- the middle ear 



a slight inflammation of tlu' sheath of the muscle itself, whirh 
produces jnTSSure on the tip of the mastoid, giving rise to 
pain. It. however, can he easily distinguished from acute 
otitis media by the fact that the drum membrane is normal 
in character, and usualK !)y not icing that there is some septic 
condition in the mouth or i)liaryn.\. width is the primary cause 
of the glandular enlargement. 

Treatment.— The objects which tlu' ])rac1itii)ner nuist 
hav." in view in the treatment of th" early stages of acute 
inflammation of the middle ear are. lirstly. to relieve pain and 
to avoid suppuration and consequent perforation ; secondly, 
in tlu^ e\-ent ot jierforation having occurred, to check the 
tendency to involvement of the mastoid antrum and mastoid 
cells ; and. finally, to stop the discharge and heal the })erforr.- 
tion. The treatment must necessarily varv with the general 
C()n<lition of the sufferer ; also win ther he is affected with a 
St vere constitutional disease, such as scarlet fcvi'r. or if tiie 
local trouble itself is the chief or only complaint ; and it may 
not Ir' out of ]>hice to impress on the readi-r the necessity of a 
careful. mctlKxlical. and systematic examination of the ear 
in e\ery case of acute specitic lever, with the view of detecting 
intlammatory changes early, and by suitable niiasures abort- 
ing them. If the jiatient suffers Irom an acute infectious 
disease and t he inflammatory condition of the ear is disco\cred 
(pnckly. thiee or \o\\\ leeches shoidd be ajijilied o\-er the 
mastoid, and hot i)oracic lomentations and amal irrigations 
employed while the nasal cavities are sprayed with a mild 
antise|itie solution, either 23 ]ier cent, ot Listerine. or a weak 
l)ora< ic solution. II. on the other hand, the inflamed state 
of tlu' ear is the only disorder to be considered, a siiaip mer- 
cmial purge is an ad\isable in it iatore treatment to be at once 
lollowed by a saline ai'criint. In adults 1 gi.iui (if opium 
may l>e adwintageously adiled to the mere' ■ • d. At the same 
time t iuee to six ItHH'hes are apj'lu d o\ er tin- mastoid prn(es>. 
close to the attuhmeiit ot the junna. and bleeding luitlier 
encouraged i)y iiot lomentations ol iioiu ,u id the exteriaj 
meatus iieiiig syringed witii tiie same solution, instead ol 
leeihes, wlikh aie sonut inu s difluult to procure, the aitilicial 



Il8 



IJAXDI'.OOK OF DlSn.iSinS OF THE FAR 



U 



k't'ch may l)c employed. If the external meatus be obviously 
involved by the inflammatory ]irocess. one leech may be 
placed in front of the tragus ; in such cases the external 
meatus should jtreviously be lightly plugged with cotton- 
v.-ool to protect it in case the leech moves. To relieve the ])ain, 
a piece of cotton-wool soaked in Batti'y's solution of opium, 
or an aural ovoid (Ajipendix) containing o})ium may be 
inserted into the external meatus. Chloroform vapour is a 
very valuable local anodyne. If these measures do not 
rapidly relieve the pain, no time should Ik- lost before pro- 
ceeding to incision of the nuinbrana tympani after a carefid 
and tliorough cleansing pI the externa! meatus. Incision may 
be ]nactised for the relief of jiain. even when no bulging of the 
membrane is observi'd. If any bulging of the memt)rana tym- 
])ani is detected it becomes im]ierative. Incision in these cases 
must be free, and made vertically behind the handle of the 
malleus, extending from the l)ottom of the meml)rane to the 
top. and may be carried J inch along the external meatus at 
tlu' junction of the posterior and suj^erior walls ; a small incision 
being often worse llian useless. Another incision advocated is 
transxerse in direction, a semiliuiar one with the convexity 
downwards ; this is not so uniforndy desirable as the former, 
exce])t in cases whert' tlu' inflammatory trouble is restricted 
to the lower ])art of tlu' ca\um txiiijiani. This slight surgical 
measure is fre(]uently ad\isat)le also where a jx'rforation is 
^mall .uid tends to Itecome olistructed. thii'- preventing the 
free exit of the i'xndati<in. It may lie noted tliat the propriety 
(it llii> luocedure has Ix'cn cpu'stioued in acute inllanimatory 
di-(»rders wiien a complication of tiic exanthemata. 

Both after incision, as well as after ]iatliological perforation 
of the nu'mbrana tympaiu lias taken jilace, the e.ir mu>t lie 
('■irelully t Icansetl \s it li some ant i^ejitic solution for exanii)le, 
litlai I per lent, lysol or that of percliloride of men iiry 
(1 in .; oiHi). Pcrexide ot hydrog<'ii is useful in tliese eases, 
as it (le( oiiip >ses tile discharge aiKJ peiieti.ites iiiori' readily 
ami deeply than the purely antise]itu i)ri'i)arations. After 
drying tlie nie.itiis. some powdered iodoloiin is blown into the 
ear, and the meatus plugged loosely from the botluni with a 



it. 



I 

1 I 

t! 



ACUTE DISEASES OE THE MIDDLE EAR 



no 



tliiu strip of antiseptic gauze, care being taken to pack the 
deeper parts equally with the more su^K-rficial. This dressing 
is changed as often as the external jiortion of the ])lug beconies 
moist with the discharge, the ear being irrigated in the same 
manner at each subsecpient dressing. Be careful that the 
gauze touch the drum at the site of incision or perforation, 
so as to cause it to act as a syphon. 

An alternative form of treatment, or one whicli some 
aurists recommend in combination with the foregoin;;. consists 
in blowing into the middle ear through the Eustachian tube, 
by means of the catheter, a few drojts of | per cent, izal oil 
in parolein. or the micUUe ear may be irrigated by the same 
route with sterilized normal saline solution. This may be 
done at the commencement of the treatment if the patient 
is able to tolerate it. and is much to be advocated if the 
medical attendant has the necessary skill. 

In cases where the inflammation tends to extend rather 
than to yiekl to treatment, even if no indication of i.iastoid 
involvement occurs, opening the mastoid antrum shouiil be 
considered ; but if obvious involvement of the antrum, oi 
any other of the complications noteil. are manifested, they 
are to be dealt with as laid down. 

Genek.al Treatment. — Tonics and attention to diet and 
gviural hygiene, as well as the use of a cleansing spray to the 
nose, are useful. But above all. sending the patient to a 
healthy locality, vvhere good air and sunshine are to be found, 
will often complete a curt; ; but this must not be entertained 
where tlu'ie is any suspicion of mastoid invob ment. 



si 



Acute Suppuration of the Tympanic Attic. 

Inflammation may be limited entirely to the attic, and not 
involve thecavum tympani proper. In t le^ec.ises the intl.im- 
matory jnocess commences in the attr'. and is suttu iently 
acute and accompanied In' such an amount ot infiltration and 
swelling of its lining membrane as to close tiie oril'Kcs lelt 
i)etweeii the neck oi the niaiieus. ilii' loi |ii.He>^i-i ;iii im u-.. 
and the constricted walls at the base of the attic. The 



it! 



}f !; 



I20 



HANDBOOK OF DISEASES OF THE EAR 



causes of acute suppuration in this region are catarrhal con- 
ditions of the naso-pharynx. ext':;.Jiing up ' ■ and involving 
the middle ear and attic. Init in which the drc^.iiagc of the main 
cavity or cavum tympani is not interfered with hy closure of 
the Eustachian tube. Hence the genuine middle ear trouble 
is very evanescent and produces no symptoms. It is more 
common in adidts than m childrLn. and therefore is a relatively 
rare sequel of the exanthemata. 

Symptoms.— Deafness, a feeling of weight in the ear. and 
pain, followed by discharge. Deafness, in acute suppuration 
in the attic, is not so complete as that which occurs in in- 
flammatory disease of the ca\-um tymj)ani pro})er. even in the 
severest forms of attic inflammation, and in the milder attacks 
there will be only slight noticeable deafness ; but in all cases 
there will be a sense of fulness and weight in the ear. together 
with more or less pain, and on examination of the patient a 
small reddish tumour will be noticed situated in the upper 
part of the drum, and usually obscuring the short process of 
the malleus, from a tendency which it has to become polyj)oid 
and dependent. This little tumour is smooth and of a bright 
pink colour, less intense than the colour of an aural polypus 
in this situation, and after discharge has commenced a granula- 
tion may frequently be noticed near the apex of the tumour, 
and by means of Siegle's speculum a small amount of jms 
may be caused to exude from the tip. In rare instances 
redness is contined to the roof of the meatus, and therefore the 
membrane of Shrapnell is seen without any Imlging. but 
pain, deafness, and fever are present. The temperature of 
the patient is rarely raised, nor does he suffer from any st'vere 
discomfort. 

Tre.mmkxt.— After thoroughly cleansing the canal, Shrap- 
nell's meml)rane. whether Indging or otherwise, is incised, or, if 
polypoid. It may Ije cut off v ilh a snare ; the external meatus 
is subsequently irrigated and hlled with aseptic jiacking. 
The gauze should be changed eveiy day. and after the ear has 
lieen cleansed with an antiseptic solution, powdered iodoform 
iT b.nii <uul i;, in^uiiiaieci. The viir may iie inflated after 
the attic membr.iiie ha-^ Ikxii incised, in order to drive cmt any 



ACUTE DISEASES OF THE MIDDLE EAR 



121 



residual pus. a procedure which may be repeated liefore each 
dressing. By this treatment, if carefully carried out. healing 
may in favourable instances be obtained within a fortnight. 



Complications of Acute Otitis Media. 

Facial palsy ; adenitis ; mastoiditis ; mastoid al'scess ; 
isolated abscess in the mastoid ; perforation of the ujiper fa- 
inner wall of the mr^stoid, with subsequent abscess within tlie 
cranium ; perforation into and purulent collection in the 
digastric fossa, with its possible extensions, as along the Eus- 
tachian tube into the pharynx ; acute labyrinthitis ; acute 
pyolabyrinthitis ; acute meningitis ; acute intradural or cere- 
bellar abscess ; more rarely acute cerebral abscess, or pyjenria. 

Facial Palsy. — Facial palsy is a symptom of no great signifi- 
cance in acute diseases of the middle ear. in which point it 
differs materially from chronic suppurative diseases of the 
middle ear. The paralysis is not of long duration if the aural 
disease is properly treated, and need not be looked upon as 
an indication for operation. 

The nerve lesion is caused by an extension of the inflamma- 
tion from the middle ear into the Fallopian canal, either on 
account of the thinness of its wall. or. as occurs in the majority 
of instances, in consequence of a small dehiscence in the 
osseous j)ortion of the wall, usually situated just above the 
fenestra ovalis. When the inflammatory process has extended 
to the interior of the canal, both the periosteal Uning of the canal 
and the neurilemma become infiltrated, and the nerve is thus 
compressed, with consequent paresis of the muscles supplied. 

Tliat variety of facial paralysis which sometimes occurs 
after cxp'>sure to a draught is due to an otitis media of a 
transient character. The treatment of this complication, 
so far as the facial nuiscles are conccrncu. should be pMi^tponed 
until the inflammatory exudation within the Fallopicni canal 
has subsided, when, if there is still any want of action on the 
part of the facial muscles, the faradic current is to be em- 
pi()\((i. ii ihc paiciiyMs. Uuwcwr. is oi long stanaing iroiii 
neglect of treatment, and tlie muscles exliibit the reaction of 



122 



li.iXDiiooK Of i)fsi:Asi:s of rifi-: f-.iR 



<lc,L,'t'n(T;iti(»n. voltuic int('irii])ti()ns of tlu' cdiistaiit currfnt 
will ;it fust l)i> fdiind more l)em'fu'ial. 

Adenitis. -The l\-ini)liatic j^lands^ soiiutinifs involved 
secondarily to an acute snpiiuration in the middle ear. are 
the ])re- and post-auricnlar j^lands and those situated heueath 
and on each side of tlu' Merno-niastoid nnisi le in its uii])er 



.J 'I! 




FIG. 40. ACUli; ^lASTOIDITIS : PKOJKCTION Or F.AR ! OW NW \ KI)S AM) 

lORWAKnS. 

third. Tt is occasionally necessary to make a diagnosis from :'n 
inflame(l suhsterno-mastoid gland from mastoiditis. The chief 
)ioint to note is that in adenitis the mastoid is on'v tender at 
the site of the tendinous insertion of the muse le. Should an in- 
flammatory swelling of any of these glands take place. .1 liy 
no mcMUs uncommon event in young ju'ojik'. resolution will 
be obtained by the application of heat, and o( a mixture of 



AC TE niSF.lSF.S (IF TIIF. MIDDLF F IR 



I-:? 



equal ]KU-ts of cxlract of hflladoniui and f^'lycorim" i>aint<'(l 
locally; the ahsorlunt action of this preparation is assisted 
in children and yoimj,' adults liy the administration of occa- 
sional small doses ol hydrarj^. c. crota. 

Mastoiditis ; Mastoid Abscess ; Isolated Abscess in the 
Mastoid.- The anatomical strmtiire ol the process has a 
distinct l.earinK on the lial)ihty of the individual to this 
complication, the larger the antrum and the more celhdar the 
hone the greater the i.rohalnhty of a imrulent collection in 
tlu' i>art. The earliest symptom of invol\-emin1 of thiMuastoid 
is usually either that of pain on flight pressure at the ui>per 
and anterior part of tin- mastoid i)r()ees^ just liehind the ear. 
or of tendi'rness on deep pressure at some other part of tlu' 
hone, usually its anterior and lower limits. With such a 
symptom it is jirohahle that sujipura'. ' ui threatens-m the 
former situation in the mastoid antrum, in tlu' latter in some 
other part of the Itone. A more or less sui)eriicial temliTness 
over the whole mastoid is. on the contrary, rather an indication 
of a general periostitis. If sui'puralion takes i)lace jKun will 
thi'ii hecome pronounced on deep pressure, hut tlu' opposite 
side must he invariahly tested to control the loult ol.tained. 
Neuralgic pain i> often felt on tha' side of the head. Fe\-er 
usually returns if it had suhsided. or a di-hnite increase in tin- 
existing pyrexia takes place. The temperature often rises 
rapidly, to 103° or 105° F.. and is accompanied, especiallv in 
children, hy a slight rigor; in adults the temperature i> at 
times not raised ahove the normal, or it may even he occa- 
sionally slightly suhnormal, an^l no pahi complained of except 
on direct and tirm pressure. The discharge from tlu' n.eatus 
often ce.'ses eutliely when suppuration occurs m the deeper 
parts, lo reapjiear twelve to twenty-four hour.. Liter ; at other 
times no alteration m the (juantity will he noticed, l-iedness. 
swelling, and (edema, which latter may he very extensive and 
involvi' the temporal fossa, are present over the mastoul m 
the majority of instances, though they are ol)Servi'd le>> fre- 
quently as the patient's age advances. Tlu' softer and more 
V,-:"-ous tlie hone, tlie greater the rapnhiy uiih uhi. ii iiiw 
redness and swelling appear ; if treatment he .lelayed pus 






124 



f/AXDIiOOK OF DrSHA'^rS OF IMF FAR 



If 1; 



collects beneath the {xTiostt uni. the ear projeets from the side 
of tlie h( ad. heint; pushed forwards and downwarils hi children, 
forwards in aduhs. and thutuation may readily he det. eted ; 
the altscess may. if untreated, extend over the whole of the 
mastoid and upwards towards the temporal fossa. It is a 
fact, however, that with the external perforation of tiie bone, 
and the collection of pus beneatli the periosteum, the danger 
ot intracranial lesions is mucli lessened, As additional 
evidence one may hnd bulging of the posterio-sujtenor nieatal 
wall, and slight .lystagnnis. 

Ikk.\tmk\t. — Whether or not the niemhrana t\ i.ipani has 
been iieriorated. e>])- ci.illv iji children, the aj'plication ol three 
leeches o\er the mastoid lollowid l)y hot boracic foiuentations 
to c(>ntinue the blt-eding, will again and again cut si ort the 
l)rogr(>-, ol acute mastoiditis, though, if these have already 
been employed just pie\i<iusly to the mastoid invoKcment, 
I'lii'ir re-employment is not ad\isai)le. Some obserNcrs 
recommend the anti])hlogist ic properties ef cdld. applied iiy 
means of a coil of ndib'-r tuliiiig through which cold water 
is allowed to llow. in the miijority of iiistaiKis, however, 
it will be iouiid th.it leedies and hot fonu ntations are a ore 
certainly abort i\c mode of treatment. Hot borac i( irrig. m 
ol the me.ittis i^ uways benelicial and often alleviates th' 
I'atient 's Milferings. If at the end of twt nlydom- hour.i there 
is no good e\ldence th.it the disease is lieing controlled, 
the pi.K titiourr cannot loo stionglv urge the necessity of 
imnit diate opei.iiion ,md he nnist point out the dangu tin re 
is m anne( < ss.uil\ del;.' ing lli.- o|m ning of the mastoid .mtrum. 

if. lio\\i\-er the c.iM' has jpii n .illowed to go on mitnated, 
or it. disj.ite tn.itmc' I ,111 abseess i> present on the mastoid, 
It will HI ( IiiMk 11 b.' nsuallv bnind tli.it the j>u> h > peilor.ited 

the outel l.iy, 1 ot ijir liolir. In these ( ,lSe> the |Mtlent 

may In unable to -let p on .u c omit of iln^cxTie ji.iin ; the 
temi'eratme is mcie.iscd, .Hid th.le ,ue 111,11 ked -.If^lls ol 
< on^tltutioii.ll disturb, ilKe. II the .lbsc(ss extern, ll to the 
i)one IS not op.iied ll will lollow thr ( ourse of any other ,i( iite 
abscess. Sleuthing w ith ( oust .nu nt pel foi.it ion of the skm, 
will t,ik( pi, IK , with .1 flee dischurjje oi pu.s. and a Miia.-. will 



ACVTE nfsn.isr.s or the middt.e ear 



125 



lie K'ft Ic'adin;^ down to tlu- ti'inporal lione and coinnuinicating 
with tlie mastoid antrum. In other cases the antral abscess 
will discharge itsilf into the externa' neatus by a ju-rforation 
of its superor 01 posterior wall. In other instances, and 
usually in adults where the outer talilc is of consideralile 
density, and whrre the mastoid ]n"oeess is formed entirely 
of (tils, the pus may perforate the outer wall of the digastric 
lossa. and then, following the direction of the fascial jilanes. 
jiresent itself in the jiharynx. naso-]iharynx. occipital region, 
or lieni'ath the sterno-mastoid musrie this \-arif1y is known 
iiy the name of ' Bezold's mastoiditis ' — and occasionally at 
tlu' same lime pus may find its way into the sigmoid groove, 
and an acute extradural aliscess be formed. 

V.vcciNE TmCK.M'Y.- -Allusion nmst be made to the em])loy- 
mciit of vac( ines in the tieatnuiit of suppurativf conditions 
in the middle lar extcinal meatus, tempoi'al hone, and 
meningeal inflammation of aur.d origin. it is rai' that 
\accines are to Ite jns'iried when suppuration is iircscnt 
in the bone. Imt in mild subacuti' cases of middli-iar sup- 
jiuration. and in all cases of nieningcd infe( tion, thev siuudd 
lie ;in])!()yt'd. 

Acute Labyrimnitis. -Occasion. dly. durmg the comsc of an 
acute otitis media, tiie patient will ( Dinplain of vertigo. This 
will mean that tlu l)ony capsule of the posterior half ot tin- 
lal)yriiith h.as luidiue intlanied. and although. e\en if no 
operation is und( rt.ikeir it is extiemejy imlikelv th.u tlie 
laliyrinth will liecome the seat oi purulent iiiflammation. 
yet it is more than probalile that it this >ymj)toiu i> not made 
the indication for immedi.ue oji ■latioii. llie inflammation may 
sjuead into the anterior half of the lal>vim'h and the ((uhlea 
l>e( onie iiiNdhi'd as well. 1 his w ill mean that on tiie re( (i\ery 
ot the patient almost (omjil'te l^l^^ of luaring uill follo\\ ; 
so th.il veiiigo 01 (lining m a (diii^i nf ,m a( ule otitis niedi.;i 
m,i\- lit eousidt'reil as a delinite le.ison tei immeiliati opeia- 
1 len, diesjiiti ,v\\ apj/aient !( uih lu y 'or tlu disi .isi to sul>.-.ide. 
W lieu Jills ol in-, entry nito the lahyiinth, all tiie >ymptoiiis 
des( riiied (Hi ^ . 259 will lie present. 



126 



HANDBOOK OF DISEASES OF THE EAR 



\ I 

If;! '\ 



!iiav savo tlic hearing. For the treatment of the latter, 
see p. 2()i. 

Intracranial lesions will be discussed subsequently {;}.'iAc 
]). 2S2 (7 S''(/.). 

As se(juel;e. adhc^sions within the cavity of the tyni])annni, 
fixation of tiie malleus with a tendency to deafness at a 
subscfjuent period, and not infrequently otosclerosis may 
occur. 

Acute Tuberculous Disease of the Middle Ear. 

It is not to b(> wondered at that the middle ear. with its 
irref^tdar cavities, mmute vessels, and fn-e lymphatic sui)ply, 
should occasiiinallv be the site of acute ttd)erculous inflam- 
HKition. This variety of middle-i'ar disease is itself a com- 
jKirativi'ly rare c(.mplication. and but rarely found in patients 
ahcady the subjects of pidmonary tul)erculosis ; it would 
1 Ik re fore ajijiear to be frequently a jirimary tuln'rculous 
lesion, the bacillus finding a lodgment in consequence of some 
local loss of the power to condiat infection, either in the 
middle ear itself or in some iiart of the mastoid process. When 
the disease is secondarv to a puhnon.n ' lesion, it usually occurs 
late in the diseasi-. and as such will rarely l)e seen by the 
aurist. and it then has a very serious significance. 

Sv.MPTOMS. — The Siihjictive Symptoms consist of deafness, 
tinnitus, a sense of fulness in tlie ear. and discharge. The 
deafness is often sudden in on^^et. and fou 1 without any 
acute inllammatory state of the naso-pharyngeal mucous 
membrane. Pain is stran^tly alisent in the majority of 
inslancts. When ]ire>eiit. it is usually >>light and transient 
in rliaraeter. and may ceitaiidy be said never to apjiroach 
in ;ieverity that usually expiriem ed in .-.imple inflammatory 
c.i.ses. I lie tiiiiiilus |)ieseiits 110 sjh( ial features. 1 he dis- 
charge is usually waterv .ind scanty. 

Objiilivc Symptcms. ( )n examining the ear with the 
sp^i(uhim. .d'i 1 eh aiisiiif4 tin iiiiatus it may 1m j.fissibl, to 
ihtiit a |iei Ini.it ion. usualh' siin,ile(l in the anterior part 
of the illUIIl. whilst the postel ior segii-'Mt Is inilf^iii^'. and 

,-^ ,. . ..1, .. . 1..1I . .1 . ;,j I ... :.l .1 1 .. I- 



ACUTE DISEASES OE THE MIDDLE EAR 



127 



ramifying across it. or a uniformly dull red hue. The mem- 
l)rane never presents that briUiant red colour seen in non- 
tul)erculous inflammation of the mucous membrane. The 
swollen drum also exhibits a peculiarly sodden and thickened 
appearance, and if pressure is made upon it with a probe 
there is only slight yielding and but little pain produced. 
Frecjuently there is slight fever, but the jx'culiarities of the 
inflammation consist in the relative painlessness of the per- 
ioration and the ])athognomonic appearance of the drum. 
Knlargemenl of the post -auricular lymphatic glands is occa- 
sionally found. If the mastoid cells or antrum form the site 
of the i)rimary infection, a rapid and i)ainless mastoiditis 
ensues, with the formation of subperiosteal abscess, charac- 
terized by the absence of the common acute symptoms, 
(Specially of iniin. Tuliercles are said to be visible in the 
tympanic memljiane in certain cases as grey, pearly spots. 
Tile process will, in such instances. l)e more acute, and a 
more rapid destruction of the tympanic mend)rane will take 
jilace. with a correspondingly rapid involvement of the sur- 
rounding soft tissues and bone ; it wiU then l)e accompanied 
l)y severe constitutional disturbance. When the membrane is 
ol a dull red colour, imdtiple perforations are often seen 
(;;(/(• Plate IV.. Fig. 2). Facial paralysis is frcqtu-nt. 

Tre.vtmknt. — In primary tul)ercu'ous disease of the middle 
ear the drum should be incised under a general anaesthetic 
through the whole vertical length of the most bulging poriion ; 
after incision, the posterior segment of the cavity of the 
middle ear is to be carefully curetted with a small stiarp .scoop. 
It is well to piixrve for microscoinc examination all the 
lissuo removt'd. since the jjresence of tubercle bacilli may be 
ilenionstrated in the debris, or tiie diagnosis may be verified 
I'V the inoculation of some of the material into a ;>mall rodent. 
Ihe surgeon will notice that there is no imniedi.ite tendency to 
coll. ipse of the m<Mnl)rane. a fact which demonstrates that 
till drum and the iiiembi.uie iinmg the mitidie ear are vi'iy 
uuK ii swollen, and that the bulging of the drum is due more to 
cell-inliltratioii and cell-proliferation, with the formation of 



128 



IIAXDnOOK OF DISEASES OF THE EAR 



|:> I 



IIj 



i ! 



After rurc'ttage tlie cavity of the middle -ar must be well 
Hushed with a 40 per cent, solution of lactic acid through a 
Hartmann's cannrla. This irrigation is repeated at least 
onc.> daily by the surgeon, and the wound in the drum kept 
open bv breaking down by means of a probe any adhesions 
whuh iiiav form between its edges ; the meatus is to be plugged 
with a strip of gauze after blowing in some powdered iodoform. 
It is needless to say that this local treatment must be 
supplemented by a proper constitutional regimen, and it is 
always advisable to examine the naso-pharynx with a view 
(,{ .u'-^eovering whether or not there is any discharge ..f pus 
from the Eustachian tube, as the pharyngeal vauh or the 
laryiiK may in this way become infected. 

Should the disease not yield to the above line ( re.ament. 
or the symptt-ms be fulmin.itmg in character, or , e mfeclion 
be primarily of the antrum or mastoid cells, then a most 
careful and" thorough radical mastoid operation ought to be 
performed without unnecessary delay, and every vestige of the 
mucous membrane of tlu^ middle ear and of its subsidiary 
cavities, together with every trace of inflamed and disease* 
boae. removed. iTlu^ general description of the radi<al 
operation will he found on p. 21,].) Once the diagnosis is 
made. It is obligatory that the patient or his friends be made 
thoroughlv acquainted' with the serious nature of the diseiuse. 
and that. iriM.d though it may appear to hini. it is capable of 
infixing ln> whole system, and th.it. through the least 
n.gligen.e on lus part, it may pro.hu e the most serious 
eonsequ.nces. lie must be enjoined to , leans.' .lailvhis naso- 
,,l,,irynx liv ni.ans ..f nasal irrigation, 1-or this ]nn pos,' tlu'iv 
IS nollunm.l.usaul.'rthana J5 1H1 ^■^•'i'-^"'"ti''""' I-'''''''""- 
AsseeiueUe, ulceration m th. naso-pharynx is toun.', though 
conir.arativ.ly rarely; the muco-piis .Iroppmg cU)wn Ire- 
muntlv ml.'cts the larynx, an.l also, by passing nito Wn- 
alimentavy .anal, .aus-s t^eiu ..i! mUcti. n. Operativ.' treat 
,„n.t to b.' .n.ctive must be pn-mpt. The mastoi.l cUs 
,„,,.„„„. i„t,., I, .1 h-oni the mul.Ue ear. ami a huge and ragged 
r:..v..!v !.,)im-. m ihr t.iiMH.r.d \>onv. .U'stroying 11 entirely and 
ini.iliiig th. syst. n\ generally. 



ACUTE DISEASES OE THE MIDDLE EAR 



129 



Tubercular Disease of the Temporal Bone in Children. 

'Ihis IS by no means an uncommon condition, and though, 
foi-tunatily. often unihiteral. yet may he bihiteial. The 
attack is generally very insidious, and is accompanied. Init 
not usually ushered in. by a discharge from the ear. for the 
site of attack is most commonly the soft growing bone of the 
I)etrous and mastoid in children of tender years. The 
squamosa is extremely thin and is separated from' the petrosal 
l)y the squamo-jntrosal suture, and the mastoid process is not 
yet d.'veloped. Pain is rare— at all events, is imt a i)rnminent 
symptom. Post-aural swelling, soon followed bv fluctuation, 
and. quite cmmunly, by facial palsy, is frequently the first 
thing that the parent notes. This is due. no doutit.^ largely to 
the fact that the sufferers are drawn from quite the poorest 
and worst nourished class of the community. A'l.-emia ,ind 
cachexia are markerl and. of course, great." if not absolute, 
deafness, and pr()l)al)ly facial palsy. 

Treatment —Local operation, and that of tlie most radical 
nature, is imperatively (h-inanded ; and it should be borne 
m mind that the i)rocedure is one of surgical necessity, and 
not an ojum ilion undertak- n for the usual reasons which 
demand a mastoid operation, for failure to era.licate the 
disease means death to the itatient. 

On cutting down through the ordinary i)ost-aur.d incision, 
a setiuestnim. embracmg at times the comi.lete temporal 
«.\<Iiisive ot the siiuamous portion or onlv jiart of the bone, 
will, in tile majonty of cases, be found." This must be ali- 
stracted. and if the anatomv of the idult bone is consi.ler. d, 
(Ins presents a sen.nis danger; but. fn-Mmatelv. in children 
the carotid canal is m.t yet formed and tlie bulb'ol the jugul.ir 
vein is not .Midangered. The only structure injur, d is tlie 
la. id ner\r. .uid that will prolubly be destroyed. 

liie wiiol. ,,ivit; IS iM.w (an fully and.' cnnscienl iously 

' "letl.d and as lar as j)o.ssible reduced t le bounded „nly 

l'\ librous twsu.'. whicli is wli .leaiiMd uilh _■ per cent, 
loinialiii cr l,i>tu \ stnjiiL: schil k.m. 



T30 



I/AXDIIOOK OF DISFASF.S OF TllF FAR 



i !9 



Acute Hsemorrhagic Otitis. 

This variety of otitic media is. in the inajoiity f^f instances, 
an accompaniment of or a seciuel to influenza, though it does 
occur whliout known cause, and is occasionally a com- 
]ilication of r< nal disease; it may also accompany a mild 
attack of othis in patients afflicted with the luemorrhaRie 
diathesis. 

Symi'Toms.— The symptoms are deafness, paui. and dis- 
charge of l)l()od from the external meatus. 

Ohjcctivc Sy>n Idioms.- A'hv mendirane is not usually l^idi^inf,'. 
nor is the handle of the malleus reddened and broadened, hut 
the mend)rane itself shows in the early stages a dull red retl(-x. 
without material interference with the cone of li,i.;ht. This didl 
red reflex is due to an engorgement of the nnicous mend)rane 
covering the inner wall of the tym])anum. and resembles 
in hue the dusky redness of tlu^ i)haryngitis of intluenza. 
When luemorrrhage has taken place, usually in infhieiizal 
cases about the hith day. the drum exhibits, at tlie lower 
and i>osterior parts, one or more small haemorrhages ; some- 
times even a small adherent clot of hUnn\ may be seen in the 
same situation (Plate I. Figs. 7 and S). The duration of the 
complaint is about a fortnight, though, if due to abnormal 
conditions of the I'lood or generJ systemic disease, relapses 
occur. 

Tui;.\i.mi;nt.- If the case lie >.een iieiore luemorrhage has 
occm'ied. and the rdjulit jciu recognized, con>litutioMal trea'- 
ment may aliort or control an attack. Lactate or i>hosphate 
of (alcium. in 10 to 15 grain doses, seem to be indicate<l. or 
small and frt(iuent do:.e:. of one of the ]>r.parat ions of tlie 
suprarc n.il ( aps\ile. After a luumorrhage ha,- occurred tlie 
ear should be lightly |>lugged with a ^triji of antiseptic gauze ; 
if there is mu( h i>ain. either tii^ L;.iuze may be moistened 
with a lew mmims of l^attey's solution of opium or an aural 
o\(iid (dut. lining opium inserted. It is not advisalile to per- 
form par.iceiitesis of the drum for the relief of pain in these 
(-:!■-:-- :i'. !!'.:■ !<^!ni»rrb.'.: ".' u ! ! !'. ii ', !i>^ui s n.!-.L\' c-ituse (( II isideraljli: 
anno\ance. 



ACUTE DIsn.lSF.S OF THE MIDDLE EAR 



Serous Catarrh of the Middle Ear. 

Causation-. — Serous catarrh of tlio middle c^ar is invarialily 
secondary to an intlanied condition of the naso-jjharyngeal 
mucosa, however slight or transitory this may have b.en. 
Careful cross-examination of the patient will always elicit 
the fact tliat. shortly before the aural trouble was noticed, 
lliere had been symptoms of nasal or naso-jijiaryngeal troul)le. 
The inflammatory process travels up the liustachian tulie 
by continuity of tissue, causing obstiuction of its lumen, 
wliich results in an excessive secretion, serous or nuicoid. m 
the middle ear. The outlet being c chided. the lluid lajndly 
accumulates, and after subsidence of the swelhng of the 
mucous membrane of the tube, the secretion r^ mains in that 
portion of the cavum tym])ani wliich is situated at a low. r 
level than the tymi)anic orilue of the Eust.uhian tube. It 
is rare in adults to tind both ears affected at the sanu' time, 
but sul)seqiient attacks are common. 

Sv.Mi'TOMs. — The chief subjective symptoms are a iiKjre 
or less pronounced degree ol deafness, a sense of fulmss in 
the ear. tinnitus, and occasionally patients express them- 
selves as feehng as if ' something rattled m their heads ' when 
they moved about. Not uncommonly there is a kind of (l<.ubK- 
lu^aiing complained of. the tone and pitch of a note Ining 
altered on the side affected, while autoplionia is a very constant 
symptom. 

Objective .S"jV;/s-.— Tlie membr.uia tynip.mi is 'ot \-isib!y 
altered in curvature. l)ut the cone of light is hiu r— that is 
to say. sliglitly more horizontal— not often divided, but 
showing th.it there b an alteration in the general curvature 
of tlie drum, though not suICk ient to l)e ajiiirin iated l)y tiie 
e\e. Tlu' most valuable ^ign. however, is the proeiice of a 
dark curved line across the drum, with its con( avity upwards 
and \\<. h.igher extremity posterior, simulating llu .ip.p, .ir- 
ance ui a hair lying across tlu tyiiipani( membrane. Ihis 
line of demarcation indicates the ui)per limit of the thiid. 
1 he cause ol tb.is lip.!' !>.i'i!i;.' ;:* ■•. !:.•,•..-:■ 1..-.-..1 ■.:•. f-.-, :-.i j- .'..... !.. 



!f 



it- 



(Xtendiiig to the lower margin of the tympanic orilice of 



132 



ii.ixdhook or disi:asi-s of the i:ar 



the Eustachian tiil)e. the higher level Ijehind being clue to 
capillary attraction. The line is caused by alisorption and 
refractiun nf the light rays as they pass through the upper 
surface of tlie fluid. 'Ww part of the membrane l)elo\v the 
dark line may ai)pear (juite normal, signifying that the fluid 
is com])oseil wliollv of clear serum ; or this crescentic j^ortiun 
may be straw-coloured, due to tln' darker colour of the fluid ; 
or lastly, it mav have a yellowish-white tint, caused l)y llie 
nuxture of a nlatively large amount of mucus. ( )cc;isionally 
the whole membrane is dividetl into daik circlets with white 
Centres. '1 lies.' are small lnll)l>le.■^ of air and tluid. A similar 
appearance may W- ohtiiined after inflation il the tympanic 
cavitv contains much fluid, as it is tlien made Irotliy. In 
rarer instances e^]HM irdly in childhood, the whole or a jiortion 
of the memliraiie mav I'e distendetl, with or without sliglU 
inflanimatorv IiIunIi in the region of the handle of tiie m.dleus 
in children. In these cases there will hv no hne of deman a- 
tion i)resent. and it is often noticed that the bulging drum 
is wlute and rather dull, suggesting, rather, that the bulging 
is due to air and not to fluid. 

Tkhat.mknt.- — Tlu' principles which should l>i- iollowed in 
the tnatmeiit of this disease are. llrstly. t-i obtain a free 
I)assage of tUnd from the ear into the naso-pharyn.x ; and. if 
this fail either to promote absorj)tion of the fluid in the ear, 
or to expel it. Preliminary treat ment consists in the adminis- 
tration of a mercurial purge, tolloweil by a saline draught. 
Inflation of the middle ear mav be satelv attempted in order 
to drive the fluid from the ( a\ um tympani down the Eus- 
tachian tube into the na>o-phar\nx. but it is ad\isable. hrst . 
to wash or spray <iut the nose and naso-ph.uyn.x witli a mild 
antiseptic, a.s i in lo Listerine. 

The nasal deteigent spr.iy is heliilul (.\iij>endices i ami z), 
and !>enzoic vapour should be ndialed and exhaled through the 
!iost' ; cidoride ot .munomum \-apour nuiy be substituted if 
the patient is unable to remain at home. ;ls no patient ought 
to be alloweil to go out of doors for at least oiii' hour altt'r the 
..... ,,t ., ,, ,, ,,, ,,,1, ,1 .t ;,.,. 

'Ihe suii;ic.il or miniedi.ite treatment consists in an iiuision 



ACUTE DISEASES OE THE. MIDDLE EAR 



13? 



of the drum, and the siihsiHiueiit cNacuation of the fluid from 
the middle ear hy means of the air-(h)uehe or by suction. As 
a f^eneral rule, incision of the membrane is neither advisable 
nor necessary, lor serous exudation 'Iocs not tend to l)ecomc 
purulent ; and. except in tlie cases where '-onsideraljle dis- 
tension is found, this is the case in the bulging drum referred 
to as occmning in children, as they are semi-chronic, and the 
continued prehension of the membrane will leave it very ill 
<il)leto resist the least microbic infection of thecavum tympani ; 
iitiierwise it is only when a nu)re sjx'cdy cmv is demanded, 
or wlu'n the mucus is very thick and cannot be otherwise got 
rid of. that incision is permissible ; but in the exceptional cases 
incision is imperative. (For a description of paracentesis, 
see p. Kjf).) Rather than the usual incision, it is advisable 
in this comjjlaint to make the crescentic incision close to the 
lower edge of the drum, and as it is very difficult to dislodge 
this thick mucus, even through an opening so made, it will 
often be foimd necessary to insert a small tine probe with its 
extremity hooked, in order to extract the ten.icious mucus 
which cannot ])e expelled by the air-douche. If an incision 
h s l)een made, the after-treatment must be carried out n'ith 
the strictest antiseptic jirecautions. 

This serous catarrh of tlu' middle ear tends, if recurrent, 
to <U'gen.erate into a chronic condition, and so may form one 
of the causes ol chronic middle-ear inflammation. 



CHAPTER IX 

CHRONIC NON-SUPPURATIVE DISEASES OF THE 
MIDDLE EAR 

It '.;^ ciistoinaiy until coniparativoly reinu ytais to f^TOU]' 
under the compiclu'iisive title of chronic dry catarrh at least 
two distinct affections. The combinatiou of old observations 
with recent work now makes it possil)le to distinguish more 
clearly, and to describe with some accuracy, the two diseas... 
to which we have referred — namely, .i chronic catarrhal o' 
sul)inflammatory jn^ocess. teriued ' otitis media chronica 
adhesiva.' and a specific condition, the origin ( t which is 
but partiallv understood — namely, otitis media scleros '. As 
will be seen, these two complaints may coexist in tin same 
patient, the one or the other predominating. 



,1 1 



Otitis Media Clironica. 

Chronic catarrhal otitis media- otitis metlia chronica 
adhesiwi \'el hypertrophica — is a pr(tgre>sive. insidious, and 
subinllammatory afiection of the middle ear. consequent U] on 
extension of so-calKd catarrhal inflammation from the 
mucosa of the naso-pliaryngeal space, which involves, firstly, 
the I'jistachian tubt'. and eventually the middle ear. This 
ilisea^e is founil at all periods of liiv. though it becomes more 
common aN middle age approaches, and then diminishes in 
frequency. There is strong evidence tliat heredity }ilays 
an imi)ortant part in tlu; production of this complaint, although 
in this instance the ancestral influence is more plainly notice- 

.,1.1., ;., .1,,, tr..-.^1.,t-,,,,. t/i *1^.. .!,,,.. ,1,1. ,..,,,«+ ,,f ..,i.,i-,.,;,i ...,,,,^*n_ 
il;.-j\. j:: :::• .• ii:- !^--y • v -a-- ■:• • v ;—| •;::■.:! t ••: ■%.■■■■ :--.i- -■ ^,- 

tion^ in the naso-jiharynx. Heredity has also a share in the 

IJ4 



cnhoxic xox-srpprRA tive nisi:.isi:s 



135 



<luctii)n of the highly archdl palati 



ul narrow facial 
(lt\ilopnunt. l)oth of which tend to an undue contraction 
of the interior of the nose. The development of adenoid 
vegetations in the naso-phar\-nx is undoubtedly more common 
in ci\ilized than in uncivilizeil races, for. at the same time. 
tlu' infections of all sorts are more common, and. consequently, 
as civilization advances in any race, -o will the pnvalencc of 
adenoid vegetations become more marked, the more so if. 
at the same time, the climate is such that the air is frequently 
highly chargi 1 with moisture. 

Course and Symitoms. — The onset is gradual, and the 
affection is not infrequently at first unilateral, though after 
a C' rtain lapse of time the otli' r ear l)ccomes involved. This, 
however, may not occur until the disease has obtained a 
considerable hold on the one first affected. The ear affected 
later is influenced by the tendency which exists for the sides 
to synergize in all those cases of middle-ear disease not due 
to the effects of suppuration. It will l)e noticed in all instances 
in which this svn:})athy occur- whether in this disease or in 
others to be considered later, that the ear hist affected is 
commonly the one least amenable to treatment. General 
conditions cf the system, such as anaemia and gout, the effect 
of malarial poisoning, dyspepsia and constipation, all have 
unfavouralile effects on aticnts suffering from this complaint. 
In common wiih othei chronic m -suppurative diseases of 
the midtlle ear the influeni ■■ of obstructed nasal rcsi)iration, 
whether in the nose >T naso-pharynx. is most marked. 

Deafness and nois^ s in the head are the principal symptoms 
of this disorder, to wh. 11 in the later stages may be added 
vertigo. In tlie first instance, the patient will notice a 
transient deafness occiuTing whenever he is atilicted with a 
nasal catarrh ; such an attack will .'resent the symjitoms 
alluded fo under acute obstruction of the Eustachian tul)e. 
an ' also those of acute serous catarrh., though without any 
serous flui'l being seen in the ear. The deafness inav be 
accom[)anied by tinnitus but the patient rarely seeks r( hef 
unless, on the subsich ncc of thi- catarrh, his hearing-pov 'T is 
dimiu'slied. \h> u he does seek medical help, it is for symp- 



1 i 

I 

'!ith ' 



136 



iiASDisooK oi- ijisi:asi:s oi- nii: i:ar 



toms (liiu primarily to obstruction of the Kustachian tul)(\ 
secondarily to tlie effects of tliis obstruction on tlie middle ear. 
or it may i)e to the conserjuences of inflammatory and sub- 
inilammatory attacks in the cavum Lvmpani. The results 
are the formation of adhesions and th'ckeninf,' of Die mucosa, 
which interfere with the proper movements of the drum and 
ossicles, and passage of sound-waves iliro.i^'h the dium. In 
others an atro])i/ic condition is noted, and 'he membrana 
tympani is extremely attenuated either w v or ui par . 
Another result of these conditions is the excessi\(' (oneavitv 
of tl:e drum and retraction of the malleus. tof,'ether with 
contraction of {\\v tensor tymjiani nmscle and of tlu' lij^aments 
of the malleo-incudal joint. The patient notici'S that after 
each successive cold, with its accomjianying deafness, the 
tendency to recovery of the lu aring is delayed, anil eventually 
th<' recovery is not com]>lete. The recovery of luariuK after 
the cold is often ushered in by a sudden noise in the ear. 
frecpiently described as a loud rejwrt. This is due to the 
jiassage of air through the previously blocked h:ustachian tuix-. 
The hrst indication that the hearing has not returned to the 
normal condition is a difficulty in grasping and comprehending 
general conversation, and pi'rhaps a tendency to carefully 
present one ear to persons with whom tlie patient has to 
convrse. This gradually increasing deafness may have 
existed for several years before he seeks relief — that is to say. 
before it has caused him any real inconvenience. Sufferers 
from this comi)laint. if previously ]iossessed of ;■. musical ear 
will 11(4 infrtquently suffer the most intense tliscomfort and 
annoyance from music which before had gi\rn them much 
pleasure, and sometimes these feelings become so great that 
they are absolutely unal)le to listen to limbic in any form 
with satislaction. This conditi(>n forms a variety of hyi)er- 
.X'stlusia acustica. and i^ often noted with (ither sounds besides 
those ol music, especially in persons of a neurotic temjMra- 
nient. In the earlier stagis of the disease deafiuss is \ery 
variable. disapi)earing freijuently with a sudden noise like 
a small explosion, and varving with the state of the atmo- 
sphere, the patient frequently i)ecoming dealer when the 



cnjx'ox/c xoxM-i'i'ciy'.rm i: I)!s/:asi:s 



'37 



jitinospluTo is surcluirped witli nioistiirc. livi-n in the rurlicst 
st:i,!;fs. liowrvcr. if sTicli a jiaticnt ]>v cxaniiiu'd caniullv 
l)(.'t\vt_'tn till' attucks. i)()tli sulijcctivr and olijcctivc synijitdins 
may lie deniDnstrated. The malleus will ai)})car rrtractcd. 
and the nndiu' concavity of the membrane is demonstrated 
liy an alteration in the cone of light. Occasional slight jiain is 
complained of cither in the ear or behind it. though this is 
more frecjui .. ._, a dull ache than actual pain, and it may last 
lor ^ome time. It is never severe, and is more common in 
anienric palienls. 

Autoph' 'lia (an undue perception of the Mitfcnr's own 
voi((). paiacusis Willisii (tiie better apjiri ciation ol .rounds 
in a nv\>r. and paracusis loci (the inabilitv to locate sounds) 
are three symptoms which are frecjuently found m this 
complaint, tlujugh jiaracusis Willisii does not occui tmless 
there are conditions which prevent due liioNcment of the 
ossicles, especially those of the stajies. 

'J he tinnitus of which })aticnts >uffering irom this dise;'.se 
complain is of a hissing or singing character, while an occa- 
sional variety of tiiuiitus. often a later symptom, is a loud 
anil intermittent musical sound. Tinnitus is rarely constant 
in tlu' earlier stages, and is not troublesome ; but as tlu' 
disease progresses it may b(M-ome a never-ceasing and dis- 
tressing factor. It increasi> in \-olume or intensity, and 
patients may complain that they are unable tosleipon at;count 
of it. and that it is worse, or ajipears to them to ]k- woisc. at 
night or in the early mornhig. .Mintal and l)odily fatigue, 
derangiinents of the general health, anil .-^timulanls (alcohol, 
coffee, etc.). are common causes of an accentuation of th-se 
iiritating noises. 

Slight vertigo is sonnet imes found as an early symptom, 
but tends to disajipear without treatment. 

The tympanic nuinlirane in simple adhesive or catarrh. il 
otitic media is thickened, and appears whiter than normal, is 
iloudy or stii'aky. occasionally almost parchment-like in ap- 
pearance, thotigh it may in' thickened only in jiarts. and have 
ureas of greater or less extent which rem;:in mi;iff( cted. 
Should this lie the case, tluse unaltered art as will t;sually be 



\3^ 



i3« 



n.i.\j)iio()K 01- disi;asi:s of the i:ar 



I'xct -'sivily iU';in^st(l. and if tiny art' (if small size tluj- will 
ai>inar like dark IkjIcs in the mucous m'nilirane (Plate II., 
I'if^s. 3. 4, 5. ()). Calcareous patches are fre(]uently ohser t 1 
a.^ well as patilies of local atrophy. thouf,'h whither ■ ; 
ctumges are due directly to tlu' disease appears doiiiitfui 
tlity are lound in ([uite youii^' i hildreii. and Iretjueiilly 1 
portion of the niruiliraue wliich may rein.uu in conditions of 
suppurative otitis. The membrane is very rarelv normal in 
appearance, and wlun so it doi-s not ictain its pliysioloL;i( al 
cur\ature. In very severe or old-standiiij; cases, tji,. drum is 
at iinits so retracted that in places no space ixist> between it 



I!': ^■' 

ill 



\\ '\ 




Fl(i. .JI. — ( AI.e \l;l OIS DItiKNI'.K.X I ION Ol IMC 1V.\I1\MI MINOlK.XM. 
(. . C.lli illCdUS )il,l<|UC. 

and thr i'lmr tympaiuc wall ; \\\ fa> t . the nundir.inc i.s -oine- 
t mil s M en lif;hl iy adherent to the inner wall. 

.\- I be ml), (I inn ol ihc < ai m this disease tend' to impro\e- 
nii ut in heariuf,'. patimts not mtie(|UtniIv jHrlorn;. tMhcr 
iiilriit Kinallv or I'V a xi'iltnt blow inf; of the imisc. \'abal\a's 
e.\pr! ini( n! / c. aui o iiitlat ion of the t\inpaiium. li this act 
It lir(|i!rnll\ K jn.ilid il ma\- < au'-e an undui' d.isti nsion ol 
till' moK l.ix poi 1 mn ol the mmdirane m the posterior an<l 
upper s( L;ni( III .md so i aiise this ai( a to appe.u to t he obseiA ;'r 
alt el mil. 1 1 loll .is a I oii\t \ piotiusion bjebdike m appearance 
01 , w lie 11 t 111 t \ iii|'.uiiiin has m 1 beep : i.tied. .is a com a\ity 
ill Willi b the lUembl.iIle is huif^ upon the he. id o! the staplS 

and |on,i; pioi ess ol ! he incus. 



ciinoxic xox-sui'i'Uh'ATi VI-: disi:.isi:s 



l^9 



Tlie luindle of the malleus occupies, in all but the earliest 
^taL;es. an al)nornial position — that is to say, it will either be 
retractid directly inwards so as to appi'ar tortshortened to 
the observer, or it will approach the posterior edge of the 
tympanic mend>rane. In the foriuer instance the retraction 
may l)e so great that the tip of tlie malleus comes in contact 
witii tlie promontory, and. siiould it remain thcri' lor a >ulti- 
ciint length of time, will become lirndy .idherent. ;ust as the 
tynipanic menilnane itself becomes attached to the long 
])rocess of the incus under similar cir( umstances W luii the 
malleus is drawn backward>. towards the jio^terior a->pect of 
the meml)rane. it ni.iy occupy any position i>et\\f(ii tlie 
normal and one in contact with the posterior fold. '1 he 
moliility of the malleus is tested \i\ means ol Siegle's s]ie( uluni. 
which will show in e\ery case tliat the range o! luiveinent is 
diminished, and tiiat in a large number of inst.inces tliis 
ibminution has lu'come absolute. It may be n marked .i^ain 
that the difhculty in ippreciating al'sdlute li.x.itinn nl tlie 
m.dleus is due to liie fai t tliat the membrane nio\-es lieely o\er 
its upper two-thiids. and that the posterior segment l)ii]ges 
torward wlier. the air is rarefied, an appearance wiin h is apt 
to convey the impression that the nialU lis ilseli is innbile. 
The cunv of light in otitis media clironic.i adhisna is ne\cr 
normal ; it is altered both in directi(ui and in lorm. it may be 
entirely al)sent from its jiropi r situation, and r( pi. ued liy a 
spot of light in an alisnlulely alniormal pbu e. In stK li e.ises 
the membrane will he almost eiiliK ly on the inin r wall ol the 
tympa. um. In the cat best stages the (one tm ins .i less obtuse 
angle with the li.iiidie tli.m normal should this siimture 
o( ( iip\- a position mote posteiioily than it ought , il the 
handle is reliacted directly inwards, tin i oii< of light bet omes 
moic hofi/.oiital than ik rmal m other words, the aiif.,le i> 

lendeled more acute. i he ( olle ol light itsell Will Hot I..I1I1 

so iie.iily to the jieiipherv of the iiK inbi.uie. It may be 
bioadei than iisii.d. may be divided into two jiai ts i oiisivting 
ol a bii^;ht point i lost' to the nmbi ami a siK.ik midway 
betweill tills and the peiiplit ly. 01 it lll.iy bi 1 1 j Hes. tit ed only 
by a bright sjiot at the tip ol the mallens. In aiU.iiu < d st.iges 



l.,o 



iiAXDHooK ()!■' i>isi:,isi:s ni- riii: i:.ih' 



tlic ])'is1t rior fold of llir iminliianr will he unduly i)r()iniiu'iU. 
aiipi'iuin^' like a l)rif^ht white rri'scent in thosi' cases in which 
tile handle (if tile malleus has .i position of extreme retraction 
(I'late II.. Fi^. <)). 

The cauMS of these changes in the IvmiKinic memhrani^ are 
twofold. The thickening of the dr>ini is due to recurrent 
attacks of intlaniiiialion affect ing its ir.ner nnicous surface, and 
the retraction of the lueudirane and alteration in 'he ]iosition 
of the liandle of tlu' malleus and of the cone of lif.;ht are su])- 
posed to 111' primarily due to the diminution of tlie atmo- 
'>|iheric pre>>ure within the tvmj'annm the ( \ternal |)ressm"e 
remainiuf,' the ■-aine. Conseiiuently the drum, i>. as it were. 
press((l inward--, f< •'. durini^ the ohstruction of the luistachian 
tul)e. tlu' air contained within the c.i\um tympani lieconies 
alisorhed or e\a( uated liv ( leariiiL; the n;i>o-pharyn\ to a 
gri-ater or Ic-s extent accordiuf.; to the duration oi the ohstruc- 
tion. '1 he >uli--e(|uent con'racti(.n of the tendon ol tlie ten>or 
tN'mjMui ,md of liand> of .idlu'-ions witlnn the t\inpanic 
ca\'itv. as will ,i-- the (ontr.iclion of tlie lii^.mients of tic 
m.illeodncudal and >l.iiieiii,d |oims. and aKo tlie w.mt ot 

leslllrlKe HI ihe t\inp,mic meinhlMne all tend to jil.A'enl 

spoilt. uieoiis lector, ii ion i if tile druiu to its normal con- 
dition. 

'Ihe state of the hJist.K hi.m tuhe as well ,is the condition 
oi the nosr and Jiasn p!hii\n\. must he i .wi \\\]\\ noted. I h'' 

|iatenr\- (i| the |-'.Ustai hl.m tulu' is del( l mni' d l>y tlie etle( ts ol 

intl.it ion upon tlh' di urn .unl li\ the sou i id- nhs, r\ed liy imans 

111 tile ail-.i idtatoi \ tuhe. Ihllat inn is aiu ,l\s 1h ttel |ierlormei| 

I hi ini:.;li till lathiiii a- 't i n.ililes t lu- oliseivei to hear more 
i'm-i ill! i!\' ,d>iiiii iiial siHinds th.m •, 'i. ii polit/,i i i/.at mn is 

tniplii\ii! illi -oimd hi aid lilioll^^h tlie i.iihelil wllell 111 

ll.itnii; an I ,ti atteit'd '.".itli aialarrhal otitis iiudi.i mav I"' 
1„ ->t i -1 I ilii d .is ills I ant and al-o a- sin.ill m iiiii m \ oliinie ; 
,11 id h-ie It sill add 111 I rm.ii ki d t li.il ,1 I ,it in III ol l,u};r I ,lhll:e 
w ill jiei nut .1 mole .(i i ui.iti • - 1 inuit mti to he m.idi ili.m does 
mil 111 -mall s|/,i . \\ h.iti \i r si/.d i.ithitii i- usi d loi di.iu;- 
no-i II iina-st ifjat ion the s.niie i.dihie slh.uM In- .idhiied to 
,il!i 1 w ,i:d,-. 1 h' I tti 1 I 111 mll.it iiu; I lu I \ nip, .mini w ill > m > pt 



m 



(11 /iv ).v /(" .\7).v ,s I I'l'i'iri TiVF. DISH. I si:s 



I lt 



ill 



the hitii" stajj;(S of this (list'asc. 



;i\f inipr()\'iiiunt in hcarjiig- 
(list.iiue an imiirovonicnt which, thouf^-li it varies accordinf,' 
to the state of tht' caMun tymiiaiii and its contents, as will 
as to the amount of contraction and adhesions ])resent will 
]irol>al>ly he increased at each successive \-isit. The duration 
■it this improvement will depend ujion whethe.' or not the 
tensoi tyni]Mni tendon is jurmanentK' contracted and also 
ujion whether there ar" many liands ol adhesions lixiu;,' down 
the stajHS. In all iirohaiulit v the degree of ann'horation is 
aKo intlueiiced li\- the amoimt ol contraction present in the 
ligaments of tie >mali joints, di'monstrated liv the amount of 
mobility the malleus exhihited with Siegle'^ ^.peculum. 

TrNi.\(i-l'"()HK TksIS in the ear'r; stages will >how either 
normal hone-conihui ion, or. more commonK'. a >liglit iui re;>se, 
less often a dinunution. '1 he increase in lione-cduduction 
is otteii pi rmaiK nt in an uncomphcated ( a-^e. Ixin,!.; probably 
due to •>onu' alliration of the ]ires>ure in the l.ibxrinthine 
tluid>. or irritability ot tiie auditorv im rve. The air-con- 
duction, hy the tunin,i;dork lest^ will i)e lowi led to .i greater 
or less I .\tent. ;md the lowest music al notes are lost lirst in this 
disease, whil.^t the inghir aie Imigi r preserx'id. When the 
disi .L.-.e is unilaleial W. in I's tr^t will show the sound li lined 
to the diseased e;ir lhou;.;h tills test bei omes useless when 
both ears are iiuoKrd. The diuiinntion in the ujiper part of 
the scale is lust detrrmiiied ii\' that lorm ol (i.iltous whistle 
called the ' ( lalton h.di Imaiiii wiustle.' or ' Pleilfer.' and will 
be Imuii.I to be i XtlenieK' sli>.;!il . llie loss ol ]m1( eptioll ol the 
lower tones will lie demonstrated li\ the Usf ot low pile llrcl 

tuning tniks and. as a geiural luli this lo>s iiu n asis wiiii 

tiir |i|ogless ol ihr disrasr. In lllr l.llil' sl.ims W In 11 tile 
stajies is llXed lU the leUestl,! owills bollr i iilldlH tloll 1, \ lie 

diminisiii d to ,i modii.ilr .imoiiiit. sjiould -ic cmdaiy laiiy- 
1 111! hine c baiif^i s III eur. boni i ondiii t ion will br mm li sIkh t- 

illed liul ill mil olUphi.lt. d I ,lsi ■, Kimie's tisl i., nr;.^,lt l\e, 

f;iiiups 11, li and y ol m\ sulidu isioiis. 1 he w.ilcli and 
ai oniuitei' will be hi, lid a! .1 sli<ii ii 1 ili-l.im 1- tli.in usu.ii .ind 
when iii.iuc ilile on thi mistoiil will be hi, lid whru .i|iphid 
to SOI in olle I p.ii t III t he I I .in ill 111 ,is I hr ?, i tli oi tin /.\L;om.i. 



H2 



iLixDJiooK or Disn.isi-s or the far 



Whisptrcd sounds .uv lost earlier and to a greatcM^ propor- 
tioiiati' rxttnt than they are in nerve cases. 

If llie stajM-s lieconies ankvlosed l)y filirous or cicatricial 
tissue-formation with the niche of the fenestra cvalis. the 
following siL;ns. together witli negative (ielle's test, will bo 
of value. These (dnsi>t in a shortened bone-conduction, a 
niarkedlv <liiub]e negative Rinne. together witli exti'usive 
(U'fect in air-conduction at th^ lower end of the scale. 

\'ertigo. or giddiniss i> a late symptom of thi-> disease, out 
may liecome >o se\ire and distressing that the ji'^ients 
ha\'e attacks markedly roemliling those of Meniere's .. ase 
(ride p. ^34). anil in which they nuiy stagger or even fall down 
suddeiilv. .\ fc'ling of nausea is sometimes an accompani- 
ment of th(--e seizures. The imcertaint\ of tliese paroxysms 
in ner\'ous jiatients tends to ]ire\'ent tlieir going out oi dooi 
un.u com|)anied. and often ( ulminates in the conditK " k iwn 
as agoiapliol)ia. a condition necessarily aggravated by the 
deafness. 

Till nose and naso-pharvnx alwavs exhil)it ( hanges iivMca- 
tive of chronic intlammation. The nasal mucosa is li\per- 
trojihied. the nasal iliambi r> irregular and nariowed. whilst 
tile iMi>tirior extremities ol tlie inliiior tmbinated bodies are 
usually hvpirtropiiied to a gn ati r or le--^ extent. Ih.r naso- 
]iharyngial nuu osa shares the h\j)ertropiiy. and is reddened, 
and m \oung jm rsons adenoid \-egetat ions are almost invariably 
piisent. (iianular pharyngitis, or later. d ))liai\'ngit i>. are 
lartlv absrjit. rngnancy and lact.itioii ap; < ai to lia\-e an 
extreim 1\- di li ill ions iuthu ni e in siu li ( aM -<. 

l)l.\i.\iisl-. l)i,iL;no>is in this complainl. whilst simple in 
uncomphcati d 1 a>e>, liecomcs mon- and more dilficult accnrd- 
ing a^ the di^i a>r l■^ ( (HuiiHcated w it h a grea'ir or les> aninunt 
I ! otovil, in>i-,. ,ind It ha> liirtiiii to be di>tinguisht d trom 
otoscii io>i'^ ;inil lhii--e 1 are ((ariition-- in whicii ob>Muctioii 
ot tl ■ hu^tai hian lulu ,ip|ir,irs to ha\i' nn pel nianeiil iil-etti 1 t 
upon till middlriar stiuctures, and is not aciomjianiid !iy 
milamniatt'i v ai 1 mn williin tlie < a\-inn tympani. 

The obje(ti\t .ipjii aiances ot tlie drum in this disease ha\'e 
lieeii deseribiii. In iiiu ompiieat( d casr-- of otosclerosis I hi! 



cv/A'o.v/c xox-scprujri ri r/. Disf-.isr.s 



1 4.^ 



(iniin IS practically ii 



onn; 



in colour and conc.tvity ; in its 
earlier sta^'es a reddish Mush appears in the region of the 
proinontor\. As there exists a large number of instances in 
whicli otitis um dia tdhesivaand otosclerosis coexist, the border- 
line :)et\veen tiiese two diseiises is hard to defme with practical 
accuraiy, anil there are a large number of cast's in which the 
aj ]i(\uance of the dn i will not render any v;duable assist- 
ance, even though it mi}' present the appearance.-^ considered 
pathognomonic of either. Reliance nuist be placed upon the 
1 ling-fork test--, us in true chronic Eustachian catarrh there is 
usiiallv a tendency to prolongation of bone-conduction in its 
earliest stag s (Rinne 7). and as the disease progressi'S the 

ndency to a minus bone-conduction liecomes very pro- 
i.ounced (Rinne Q ; whereas in otosclerosis, as apart from 
di.-MiLse of the lab\Tinth, from the moment the disease lie- 
comes cap ble of detectinn. bone-conduct ion is either nuirki'dly 
jirolnngi d (Rinne (] and au-conduction is diminislud. or bone- 
conduction is dimiuislud (Rinne (]. when the labyrinth is 
proltablv involved. In .idhesive catarrh the Eustachian tulies 
are ilimiuish' il in calilire. while in otosclerosis they are more 
])atent than normal. 

Tkk.mmknt. —The treatment will be considered under 
(i) adminislr.ition of internal ninedies. directeil towards the 
relief or ( lue ol the deafness and tinnitus ; (j) the restoration 
of tlie permeabihtv of the Euslachi.ui tulie and of mobility 
ti tile malleus and stajM^s. .ind assistance in the return of the 
(bum .111(1 iniddli' ear to a conditi(Hi of usefulness ; and ( ^) the 
'nrre(tinii ol almormal conditions in the nose and luiso- 
] 'larynx. 

.\dmi)iistr,ition nf Dru^s. — The remedy most generally 
serviciable i.-> st'.ychnia. It >liould be administeied in (lo>es 
ol iiicit .ising streiiL,'th comiiieiK iiig witli ,;,,, grain in the 
iem.iir ,111(1 I,';,, 'o i',,, grain in the male augmen'ing the dose 
i>y ,,',,, grain cm 1 sinoiid or third (la\-. ''itl. r until tlie hiiiit 
ol toll Ml ion is w ,11 IkhI. or until th(,' ]>at ieiit is taking a do^e ol 
,', to ,',,-;, grain three times a da\ acconliiig to the sex. I liis 



•iiiedv will 



loiiiul < 



■\ti< mely usetul tiotli in mipro\iiig lh 



w 



111 .11 ing power .md 111 ilmiiiii--iiiiig lillnllIl-^ m a l.uge miiiilier 



144 







ol casis. 



ii.iXDiiooh- or Df^n.isr.s or riii: i-.\u 

W'licrc this ilniu hiils to nlitvi' the liiinitus. 



(lilntc 

liy(lr()l)i(>niii ;ui<l in \ or i (Iraclini doses three times a day- 
her alone or (oinbiiud with stryehiiine. is on .isiorially 

av lie a(lniini>tere(l 



eil 



heliitul ; aiul as an ahernative lnoniKles ni; 
at iiif,'ht. 

Anothi'r \-ery m- \-i( laMe renieily f< r the rehi f oi suhjectix-e 
noists is \-alerian administered in tu)! doses. and ln^t in the 
form of one of tlie valerianates or the ammoniated tincture ; 
whilst in aniumie jiatients arsenie or iron is imiicated. and in 
j;outy patients citrate of litliia and the daily use of Carlsbad 
salts. At the same time any digestive disturliances nuist be 
attendi-d to. Ihiosinamine and lilirolysin are said to be at 
times \ery ustlul and may be triid win ii the m.dleus is 
immoliil'' or when there is reason to expect the i>iis(nee of 
cicauicial tis-ue in the cavum tymiiani if other tre.itnient 
fails. 

The onlv aiticles of diet vhich appear to l>e detrimental are 
coffee, alcolud. and. perhaps, pejiptr. l^.xcessive cigarette 
smoking s'liould be jirohiliited cliietly or. aciount ot the irrita- 
tion it ( auses m the naso-jiharynx. 

Infliilioii.- in tile majority of cases especi;illy in the earlier 
stagts of the disease, the major ]uirt of any improvement is 
ell(( t(d !iy th.e use ot jieriodic i'e.lalion. To obtam tins ensl 
there are three recogni/.ed met hods : that ol aiito-inflatitiii— 
the jirotr-s of N'alsalva judilzen/ation and intlaliun lludugh 
the eathetei. 

With regard to atito-mtlat ion. it >liould ». rcr be piocrilied. 
as the lelu 1 obtained l>y the patients induces them to repeat 
the inodss Willi excr-increasing frecjueiicy. and m a (imi- 

>ideialile number ol ( .ises It has a very deletelloUS (ll<'lt. 

>tieti lung unduly the po.Merior segment of the drum, it will 
eviiitiially cauM' increased hardnos oi h ariiig by the n laxed 
ti-sues tailing and lying upon the long prot t>s of the iiu u^ and 
the he, id ot the stapes. 

Wh.ilHr poht /.en/at ion or catheterization is resorted to 
must depend to a ( irlaiii <\\, nl uiiou the sl<ill ol the ojieiatoi'. 
liut the use of the lalhcltr iii.diKs a niou aicur.ite employ- 
ment nl the .iii-( urn lit . 



cJiiv'DMc xox-SL'i'i'Ch'.i ri \'i: jjisi-as/ls 



145 



h 



(■ ciir 



iimld lie iiilLitfil not oft 



(iuT I lia 



n tlin 



tlllK 



wcik. and ])frsistc(l in lor alxmt six weeks, or K'ss if the' 
patient Ceases to ini]>id\e. 'I lie ( ouise of inflation is to bo 
re)>eateil at the expiration of alioiit font" weeks, and nia\' i)e 
rontiinud a^ loni^ as inijuovi nient is manifest, .\fler this 
sei (ind course of treatment, or sum' times at the end. of the 
lir>t period the jiatient will lia\e ohtaintd what mav be 
termed his maxinmni amount of luarinf,'. This amount of 
hearinf,' is retained for a lonf;er (rr shoiter jieriod and the 
jiatient is to be instructed to immeiliately retmii for treatment 
at the fust indication tliat he is aj^'ain becomin,:.,' di afer. 

In favourai)le cases the length of time which elapses bi'fore 
the jxitients notice a rt'turn uf their deafness will increase, 
and eventually the condition of the i)atient will remain satis- 
factory tor Several yi'ars a' a time. 

Should no improvement be obtained after two to four weeks' 
treatment, no good i ffec t is likely to be ]iroduvC(l by (~on- 
Inining intlation for a longer jieriod ; but if no benelu ial effi'ct 
atcrnes. other adjuncts to this treatment may be employed, 
'iliese are the injiction through the catheter into the middle 
I'ar of oily iUiids. or a(]ueous solution and va]iours. < )f the 
tornier. highly rectihed paratfin dietroleum molU'). eitlur alone 
or containing iodine or menthol in solution, the former in tlie 
stieiigth of \ per cent, and the latter of i p-t r ciiit. ( )l the 
lluids, solutions ol iodide ot potas'^ium and bicarbonate of 
soda. 1 and 5 per cent, sohuions resjuet i\ely. with or without 
the addition of a little glvceiine are uselul. 

'1 he method ol employing these nnu dies i as lollows : Tlie 
lathelii lia\ ing been jiassed and ascertained to be in position 
by a preliminary use of the airdiag. 1 to j minims ot the tluid 
selt (tc(.l are injected into tiie catln tei lidiii a I'r.ivaz syringe, 
and the air-bag again eiiijiloM d. It .is small an amount as 
this is Used. It i> blown out ol the distal end ot the catheter in 
the fonii of a sprav. ami will )>enetrate and jiernie.ite the wliole 
c.ivity of tlii' middle ear. 11 more tluid is used, the llKljol 
part of It will lind its w.iy down tin luist.u hian tube, and that 
whiili is driven into the tvmp.iinini will gra\itate to the 
luittoiii ol tile ca\'um tynipani. and ,is long .is it lem.iuis there 






146 



iiAsniiooK ()!■ i)isi:.isi:s oi- rui: i:ar 



will finisc ;i tmiporiirv incnasc of (Iciitm -^s and is not pro- 
(liKtivc of an\- WWvx rcstilts fhan wlicn the siiinllrr ainonnl 
is employed. Tlicsr solutions '^1lolll(l be fin]>lovi'il i ach time 
the '.athi'lcr is used-- that is to say tlircc timi-s ,i \\rcl<. 

It is in rt'itain conditions of udhesivf middle-tar disease 



tiiat tlir Ijistaehian Louj^ie ,i;ivts very K"" 



d resn!!-.. 



'1!! 



indications for its n.se are the l>;id entry of air into tin middle 
car when inflatin.t,' tliroiij^li the catheter and improvement in 
the hearin,!,'. hnt onlv of sliort ihiration. after inflation, 'liie 
lioii-jie sliotdd lie n><'d two or three time'~ and the l,irf,'<'st size 
eni]i]ny((l. and kept i)i situ lor tiiree to live inimites eacli 
sittiii),'. and a little oli iim jn Irol injected .is dcx rihed on the 
preN'ious jia^'e. 

I'apoitis. The folliAvin;^ \aponrs are employ d cold ad\an- 
tage h(ing taken of tlieir \dlatility : acetic etlnr. rth\l iodide 
and ethyl chloride ; llu\- are \\>ii\ ritlier alone or mixed with 
a<-etic ether and tincture of iodint . a few minima Ix ing droii)>ed 
into the air-hag liefor'' inflation. This is a jtroceeding oftt ii of 
considerable benefit in the speci:d treatment ol limiitns 

Nascent ammonium chloride wiponr inhaled oi exhaled 
through the nose, or taken into tlu^ month and j)assed through 
the nose, acts locally on the naso-pharyngeal mucous mem- 
brane ; by reducing or curing thi' catarrhal state of this region 
it often imjirove.- hearing, and mav b<> safely ri'commeiuhd. 

Miilii'ds i'f Treatment jri))n Without.- '\\w foregoing methods 
may 1k' considered as treatm<'nt from within, in.isnmcii as 
they .ict on tl iviim t\ nipani and on the iniur sm^tace of 
t!u' memiir.ana .^nipani. Those atiout to |)e tonsidered art' 
employed on its outer smface \Ma the external .mditorx me.it us. 
They are rare^.iction of the air in tiie exti rnal me.itus inuumo- 
massage. and the use of the pressure-] )robe of I.ucae. 

idle rarefaction ot air in tiu external im .ilus is a proceeding 
whith is often of considerable beiielit contributing towards 
the more fon ible stretihing of adhesions Iniweeii the mem- 
brane and the inner wall of the tympanic cavity, and also 
aiding in the stn idling of the ( onti.u ted tendon oi the t( iisor 
tvmp.uii. This method is p.ii ticularly \aluable. in < ominoii 
with the use of tile jiressurt -pltibe. ill ca^cN where the h.Uldle 



ciih'oxic .vo.v-.sr/'/T/,' (/7I7, i>isi:.isi:.i 



m; 



of the inalltus is iiartially or cntirfly I'lXid. Tlu' iiulliod of 
rafffyiii^' tlif air in the txtcriial meatus is by ilu; use ol tlie 
rarrlactfur of DiUtanclic. or. liy wliat is fqually fffrctivc, 
tlu' instrti,)!! of the luhlHr nozzle of a roinprosnl Politzi'i-'s 
1).i,l; into tlic <\t(rnal iiuatus, ami allowing,' it to j.artly (■xi)an(l. 
W lii<l)(\tr ioiiii i> iix'd. ,t;rrat ( aic luust he taken itia.t the 
Miction is not too \iol,iit. Thr ]>r^\ nutlioil of conlrollinf; 
this suction i> by attaciiin;.,' the rarefacteui- to a Sief^'le's 
speculum ohseiA'in/,' the effect on the drum, and ref.;ulatiiif; 
the [iressiu'e accordin,!.; to the effects observed. 'I he <lanf,'ei-s 
to bt api'reliended are rui)ture of a bloodvessel in the meni- 
l)rane. or ruiiluie of the iik niin-ane itselt. The former is a 
matter ol no permanent moment. Imt will delay the local 
treatment lor some lime, and may catise more discomfort 
than is d.siralile ; while rupture of tlu' membrane itself is a 
nun li more serious ( unsequence. since, i^hould it be ni'glected, 
sup])uration may ensue, and the » ase become Kiuwrted intci 
one of chronic suppuration in tin middle ear. with all its 
attendant danf^ers. 

11 tills form of treatment prove beneficial, it should iie 
re])e,ited daily for some time, and may be delef,'ati'd to the 
patient's own use. provided that he is oai-efullv instructed as 
to the necessity ol axdiiliiifj; any effect exceediiif.; slif^dit discom- 
fort from the amount of suction employed The seam es 
should not exceed half to one minute to commenc(> with, and 
liv<' minutes at the outside when the ear has become tolerant 
ol t he St ram. 

1 he use of I.ucae's i^ressure-probe is doscribed on ]i. 74. 
It is well to an;L>stlietize tlii' ear liy the use of aniline oil 
co( aine solution. The pressure should be intermil tent, and 
not repeated until any intlamm.itory disturbance that may 
lia\e been causeil by its use has sulisided. nor should it bo 
employed lor more than a few minutes at a lime. The total 
dm.ition of the course must be determined by results. 

If these lesser or luihler measures pro\-e unsuccissftil. the 
malleus may i)e forcii)ly mobilized l)y exerting; sufficient 
pressure on the short process by means of the probe under 

Cot.llllr or t^elleial .lIl.L'-'t llesia. 



148 fl.lXnUOOK Ol' DISEASES ()!■ '1111. EAR 

( )t()-inciss;if,'(' or jmcTiiuo-iiKissago is clescrilH'd on ])p. 72 and 
73. and it is isiRcially necessary to l)ear in mind tlie rules 
laid down with regard to its eniiiloyinent. It may be em- 
ployed daily, and is well managed by jiatients themselves. 
It --hould not lie used at tirst for a longer duration than one 
niuuiti'. and sliould not lie iiersisted in without a relativt'ly 
long ])( riod of disuse for m<ire tiian tour weeks. 

'llu' use of this method is oceasionally followed by a diniimi- 
tion (it the luaring-power. whieli nuist lie taken as an indica- 
tion for the prompt discontimiance of tlie trt'atnient. 

In all cases attention should be directed to the state ot the 
nasal iui>sages free nasal respiration being essential to the 
leliet. cure or lueNeution of recurreuci' of chronic otitis media 
non-Mippurativa. 



FIXATION OF THE MALLEUS 

Stretching the Tympanic Membrane. 

Fixation of the malleus is a vt'ry common occurrence, and 
is often the result of a transient otitis media non-suppurativa, 
and is ]irobai)ly a condition which of itself Init little injures 
the acuity of audition— that is to say. at any rate, as far as 
ordinary Inisiness and social life is concerned. Bu* if the 
patient at the same time has olistruction to his nasal resjiira- 
tion. and especially if that obstruction l)e on the same side, 
then tlie irecjuent violent nose lilowing will gradually cause 
a stretching of the posterior half of the tympanic memtirane 
on the affected sidi\ and when this has liecomi just sutlicient 
to cause the nuMnbraiu' to come in contact with the bony 
portions of the incus and mco-stapecli;J joint during the time 
that the membrane is not Judged outwards liy the inflation 
caused by the nose blowing, some dulne.ss or hardness of hearing 
will be developed. The jiatient then will probably di.scovcr 
for himself, or he may unfortunately lie instructed to employ 
the so-called ' Valsalva' experiment, thereby giving himself 
temporary increase in hearing. This in itself tei^ls to make 
\ e patient employ the method more .iinl more Irecjuently, 



FIXATION OF THF MALLEUS 



149 



thereby not only stretching the drum more, but .it each time 
that lu 'loo? so. he causes a concussion of ihe labyrinth, slight 
and transient at tlie fust, liut alwav^ \>itli a ten ''iicy to leave 
behind some slight injury to the delicate --Iructures of the 
coclilea. or even of tlu' canals and vestil'ule. Thus the 
fixation of the malleus may be the indirect cause of a chronic 
concussion of the labyrinth, and a gradually incri'ased hardness 
ot hearing, which is entirely ilue not to the fixation of the 
malleus, but to the nasal ol)struct ion. 

I'HK.vrMENT. — Treatment here may he divided under three 
lu'adings : that directly to the malleus, ditcc tly to tin nost>. 
and directly prophylactic. Thus we may moliili/.e the 
malleus l)y direct jiressure (see Operations). Besides the 
molulization of the malleus, and .dso. preferably long Ixfore, 
measures should be i.ikeii to. a-> it weri'. restore the resihence 
of the drum ; rest alone will sometimes do this. Init the old 
treatment of jiainting that jiortion of the stretched tympanic 
memlirane with collodion is perhaps une(iualled. though it 
was tile custom a great many years since to i)aint this relaxed 
drum with strong solutions of nitrate of silver, a ])ernicii)us 
tri'atment which has of late l)een revived. We must remove 
tlie enlarged ])osterior i-nds of tlic turl)inates — if they exist — 
and otherwise render the nasal passage patent. But what is 
of the greatest imj'ortance is that we must instil into the 
l)atient's mind tlie al)Solute necessity of never blowing the 
nose. ii:.li'ss the nose is l)lown without any comjiression of 
the nares. 



MICROCOPY RESOLUTION TEST CHART 

ANSI und ISO TEST CHART No 2 



1.0 



Ui|78 

3 '! 
*- 13.6 



I.I 



1.25 



1.4 



jZ5 
2.2 

2.0 
1.6 



^ 



/APPLIED IM/IGE Inc 



n ! 



(•l[Al'Ti:R X 

CHRONIC SUPPURATIVE DISEASES OF THE 
MIDDLE EAR 



Chronic Suppuration of the Middle Ear Otitis Media 
Suppurativa Chronica. 

Sri'iMKAi iDN iif llic niii'dli' car is li\- t^i'iicral cunMnt cun 
sidi ltd ( liKiiiic alter it h,i> hfcii in fxistcncc U>v iiini'i' than 
r-ix weeks. '1 'ii> i> a )iiirelv arliitraiy (livisiini, Imt in piacl ice 
sdiiiesuili li\c (1 ]iei ind (i| time is advisalile. it may. llieretdfe. 
lie \ii'U((l as tlie se(|iiel to all aeiite iniildle-eai snp|iiiiatii)!i 
wliieli lias ceaseil to sliou aiiv exiileiice ol actixe intlamma- 
tiim. No (ioulit isolated eax s orenr in wliiih the a<nte 
(lisi ase lasts < (insiderahly lon,i;ef than tiie time f^ixcn. 'lulur- 
('iilo-,is is the most imiioitant eanse ol such eontinnanee. and 
this \ajiety has iu i ii ennsideiid nnder the headiiit; ol Aentc 

'I lllieK idons I)is(,ise()| the Middle l:,ir. 

As has hi III SI (II. all (liionK olonhieas whuh ha\f tiie 
son! ee ol their disi har,i.;e in t he imddle ear at e i he se(|n< Is to in- 
tlaniinator\' disoiih rs ol the nos, and naso phai\n\. liil.mtile 
otoiiho.i Is most ( oiii moiilw oiii' (.in almost s,i\' in\ai iahl\'. 
ai ((impanii d I i\' I he s\\( Ihiif.; ol the pharx'tii^eal tonsil anil it is 
to the |iei>istini ■■ ol ihis ( iilar,L;( nient th.it iIh eontinnanee of 
middle eai sii|.|iiii at mn in i hiMhood is laii;el\- due. In ailult.s 
il is I ss I (111 i UK. n loi a pi mi.ii \ .!( nte in Ham mat ion to mei>;e 
into a ( In oiiii mie ( Iik tl\ lot tin nasons that it is more ( asi1\- 
and I 111' \> nll\ to ,iti d .md that the jihaiMii^eal tonsil is rati 1\' 
h\ I II 1 1 1 oplii( d so ill. it llu nnddli (.11 di aiiis moi( Il adih' into 
llii n.(-(i |.har\n\. in I'ii;. j.: is i i\, n a dia^iammat i. ii jiii - 
sent,'! idi ol ,1 siiimn thmm^li the ixtein.il ni'aliis. middle 
( ai . and !■ iisiai hiaii t nhe. I'l mn this it \\ ill he sei n how the 



MIDDLE-EAR CHRONIC SUPPURATIVE DISEASES 151 

drainage of the ni'ddle car is performed by the Eustachian 
tulif. If the Eustachian tube is unable to perform its function 
on account of its orifice lieing closed by pressure from adenoid 
growth in the naso-jiharvnx. and if there is at t'.ie same tune 
supjiuration in tlie middle ear and its subsidiary cavities, an 
accumulation of pus occurs in the cavity of the mitldle ear, 
until the retained secretion has reached in the llrst instance 
the lower l)order of the tympanic perforation, wherever this 
may be situated, and in the second ])lace the jms has escajied 
through till' perforation into the external meatus, it will only 
apjicar at 'he external oriticc when it lias readied tlie higliest 



£j^: 




no. 4J — I)i\(;r.\m ii,i.istk.\tint. thi: intm i;nci: of .\oi noid vF.r.i.T.-v- 
110N-, IN riir; .na-io-i'ii.xkv.vx on' si'imtk-MIon in middle i..\k. 

I'.M. I'.xtcnuil meatus : M. in.illcus ; M T. tvm]iaiin iiu'iiilir.un' ; 
/■-'/', I'.iist.uliKiu t\il)c. .1, lr\cl 111' lliiiil in cxti-rn.il meatus anil 
cavmn tvmpani ; />'. I('\ci of iIumI in r,ir wlim ICust.K lii,ui tiibr is 
]i.it(nt ; Cr, ca\iini tynipani. 

Ivrl in tlic tldor of the canal (A), ff the perforation lies 
i" low lliis levrl (A), the wliolr eavum lymiiani will I'f ki pi 
t Dii^tantlv full of pus, and llir supimration mu>t continue so 
long as MK h a eondition exists. 

Sv.Mi'iiiMs .VNi) Signs. -Purulent discharge, somrfiines 
oUiiiMve. (M ( .isionally --tained witli lilood from ihe extcinai 
melius; ]ni loiMtion of thf memlirana tympani; drainers. 
I'.iiimts ollcii I oniplain of giddiiu'^s, .1 diN.ign r.iblc taste in 
till luiiiiili, iioi.scs in tlie car. luadaclie (general or lixali/cd). 
.imi .m 11 1 ilaliility "I ltiii|iti. Ihty aic Hot uiudmiuoiily 
11 1 1.1 Ml- to I oni ( nt !,itr thrir tlioiights ujioii any Mibject. 

Clironii .s"iY)s('s. •W'licn ->uiipurat 1011 li,i-> rxisted for a inn- 



152 



HANDBOOK OF DISEASES OF THE EAR 



I <M* i 



sidorahle pcrioil of years, tlu- patients often have an extremely 
sallow complexion, and -ntler from a constant or chronic 
malaise, which may lie asnnnd to lu' due to a chronic sejisis, 
kept lip by frecpunt ahsor])tion of small amounts of toxic 
products. In long-standing cases, or in cases where supjiura- 
tion is proceeding rajiidlv. other svni])t(.)ms may l.te noticed, 
and they are usually of sirious import. Fixed pain in the 
car or over a localized ]iortion of the mastoid, nystagmus, 
vomiting and facial paraly.sis. may he instanced in this 
connection. 

Distiidyi^c. — Though usually jim^ulent. it mav he f]uite cleur 
and waterv. An offensive odour is often \-erv noti( eal>!e. and 




Mc. .)■,. — pr.Ki oiJAim.N ov ^^ NniKANF in rosrciuoK senuioK 

nCAliK.VN i. 

SI'I', I'lrloratiim in ^u|h ihh jii»1cn(ir (Hi.icli":int ; SI', pioicssus 

bie\ IS. 



the (]uanli(\- of the discharge varies within wide limits, from 
a scarcely ]Mrciptililc moisture of the meatus to a jnofu^e 
flow. ]\> (<insi>tency may lie increased so much ;is to look 
like tr<'acli'. in llijs uspcci re^ciuMing acute olorrhoa. 

lull rniittcnt dl-^chargl■ may he due to a hgiiling-up of the 
old trniihlf after a frm|iorar\' ((station, or tc) the elfects of 
accniinil.itt d ( holrsti atomaloiis m.itirial ; in tin- fnrnu'i' c.ise 
exact I l,,it ions nt ]i.iin arc h"f(|urnt . Reciurcnt di-~cliargi- utten 
precrdfd liy rith' i (ar I'.iin or luadaciic. A >utidrn ( < ssalion 
of <liNchar(,'f ^onulnms (k > urs simullaiKoU'-ly with the on-'i'l 
ol sniiu- ol ilir st\i ic M pi ic nil i.ui.niial lisidiis. 

PcrJoralii'H of !hc Mriiilii-,niii 'I'vin />,iiii- It must not he 



MIDDLE-EAR CHROXIC SUPPURATIVE DISEASES 15^ 

taken as a si)u- qua iion that there should be in every case 
of suppurative otitis media a perforation of the membrana 
tynii)ani. Init tlie instances in wliich tht're is no such jierfora- 
tion are of very eonsideralile rarity- In i>lace of a perforation 
in the membrane a sinus opening into the external meatus is 
present, which is connected directly or indirectly with the 
cavity of the middle ear. 

Wlien a pd'rforation is present, its size and situation varies. 
'l"he drum is rarely absolutely destroyed, for even in those 
cases in whicli tlie i,'r('atest destruction of tlu' meml-rana 
tyuipani lias taken i)lace. there is a i)a t. at U'ast. of a narrow 




111.. 44. I'l.RI'OK.XriON OF Ml Mr.KANl. IN I'OSII.KIDK l.N-riCKIOK 

QCAnRANr. 

C, Hrad (it nuiUi'Us ; SP, ])r(,LCSsus brcvis ; IIM. liaiuHi' of m.illciis ; 

P, jjcrioratioii. 



Iiorder left at the periphery where tlie membrane is streiigth- 
( iird liy llie pioeiice ol a few cart ilage-cells and also where its 
nutrition i> f^icatest. 

Ca^es of perioral inn of tlie membrana tympani may lie 
conxinieiitly di\'ided mlo two threat classes pei lor.itioii of 
the inemhian.i jimpiia. or tlie true dniin and perforations 
111 ilir membrana llucida. or Sliraiinell's membr.me. 

I'erlnr.il ions ol tiie true drum dilfei in imjioit accordinj.,' 
to till ir situation. 1 iuv mav be said to increase in serimis- 

Ilis^ whrll. rnllsidrrillf,' tllo^e sini.ltcd 111 tile .Ulterior ■^Upellor 
iiuadl.llll .is the le.l-^t serious, tlnv .111 t.dxrll 111 lllr InlluWUlt,' 

nrdii. p.is^iiiL; Kiuiid the drum: .\iiteiiiir supirior, anterior 




154 



HANDBOOK OF DISEASES OF THE EAR 



iiiffrior, posterior inferior, jiosterior Miperior. This serious- 
ness of ini])ort is applical)le as regards the {)Vosi)ects of enre, 
lu arin^'-power. and the extent of the destruction of >lrui-tures 
uiiliin the middle ear. In onh'r to oI)tain a clear view of 
tile iiieinhrane it is necessary to remove from the external 
meatus all traccN ol pu^. epitlieli.d debris, or wax. This may 




Fic. .t5. — oriri^ Mi--.iii\ sriMMTR vTivA : comim.iti' ni:sTRt'(-TiON 

()|- M. r, Willi ( |i ATRI/.MIO.N. 



lie acrdiiiplidhd t iilitr hy 1^1 iill>- N\-rin,!,Mn,L; the ear with an 
anlisrptu suhitKui. wlmh i^ hrst dour with ,in iiidi,niihii( r 
'ulii' littrd lo ih( iid/yli III ilu' ~,vrini;e. or hv im ,ui> of cnltdu- 
Wdiil lucjis. The patinil >li(inl(l iiu'ai iabh' hr -■■.itid. tii',' 
sohilinn u-Mil in ihr s\iinui- nl ;i romfiirtalilc lrm|M r.iiuiv. 

and Mo : r,it (if suddill Imec imiMlled Id ihr ^ll.'.im of lot ion. 
i'.\'(il Willi llirsi' iirii:iiit ii i!w <i\-i'ii. \-,.ili..i. i. Ill ,„,,.;. .1,, lit. 



MIDDLE-EAR CHROXIC SUPPURATIVE DISEASES 155 



bo complained of ; it passes off in a short time. If cotton- 
wool mojis are eniployed. they shrmlil be attached to a ])r()])(T 
carrier ; and to a\'oid soilini;; the Un,i;trs, tlie used woul may 
lie removed either b\- usi' of <>. soiled wool-receiver or l)y a pair 
of force]is. Brisk mo\rmtiil of the mo]) in water lof)sens its 
attachment to thf carrier and facilitates detachment. Wlun 
the ])a^sage has l)i'en carefuHv cleansed, all moisture must bo 
removed by jilcdgcts of cotton-wool, as was descril)t'(l uiidi-i' 
(ieneral Treatment. 

It is well to muinibrr that, as a rrsult of cither nietlioil 
of cleansin.t,' the ear. the tissues of tlie drum and deeper ]iarts 
of tlie meatus will Ite soniewliat injecte.l. and jirojier allow- 
ance uuist 1)0 made for this hyiH'r;enua. 

Perforations, if large, are easily detected, and through which 
tlie observer in the majority of instances is abh' to see a jiart 
of the inner wall of tlie tynijianum (Plate III.). The ]iart 
sec'U will i\ecessarilv tlejiend U]>on the site of the ]ierl"i;ition. 
If it is situated in the juisterior inferior portion, he will see 
the promontory, and perhajis the f(jranien rotnndum, apjiear- 
ing as a dark shadow posteriorly. If the ixistt-rior superior 
([uadrant is gone, or it the pi.rioration ernbraci'S that area. 
he may see the long jiroct'ss of the incus, tlu' stapedius ti-ndon 
(Plate 111.. No. 7) and 
of the I'^dlojiian canal, 
tion the mucous nuiubraue of the inner tymi>anic wall will 
lia\c a ]iale \-ellow colour, or it may ajuiear flaky and white 
when It is imdergoing the so-called cholesteatomatons change. 
In eases that are more recent, or more a<ti\('. the mucous 
membrane will appear pink (Plate III.. No. 8). and should 
there be a tendency to grainilition. nodes may be observed 
on it. not unlike the smface of a rasjiberry. but oi a brighter 
red hue. Wlu 11 the i)erforation i- small, ■-(' that little light is 
able to ])enelrate ihrougli it into the cavit\' of the middle ear. 
the ]>ei lor.ttioii a^ijieais a^ a d..irk point (Pl.iti' HI,. No. ()) : to 
<i!stnig\ush it from a de]M'essed area of attenuated drum mem- 
brane, there will be no minute light reflex visible within it. 
as there Usually i~^ in sui h a condition of the nienibiaue, but 

lli.> 11^,. ,\\ <i..iil..V wn,./iitiitii (ir til.' tiitl limn li v.t will ii-mli i 



occasionally the bony ])rominence 
n a case of long-standing supjiura- 



m 



!iti 






I5''> IIAXDIiOOK or DISEASES OF THE EAR 

llio (liapnosis rlear. Tlie edges of the perforation convey 
\-aliKililc liints u]>on the state of tlie easi\ A perforation 
which lias existed for a eonsiderahle perio(h with discharge 
of not a \ery irritating eliaracd-r. will have edges thick and 
callons. Pro\-idcd there is a. tendency to tlie closure- of the 
perioral ioih or il the di>ehargc is of a very irritating cliaraeter. 
the cdL;is will lit- pink and thin: at other times the margins 
will he sharply ctit. this slKir])iu>s of definition being usually 
met with in lurluratidiis in which the discharge is either 
sli.^hr in amount or has not existed for long pi'riods. 

Perforations in tlic drum are tisnally single, hut occasion- 
ally lli(M-e are more than one. and in manv instances a second 
perforation lies in Shraj.neH's nieiiihraue (Plate III.. Xo. 12) ; 
in oilier eases what was originally a single ])erforati()n has heen 
converted into two or mon by bridges of tissue liaving grown 
across tlu> sjiace. 

Pcrlorations in the ]ioslerioi- superior and anterior inh-rior 
(luailrant are often veiy difficult to di'tect. sometimes because 
Ihcy arc so situated at the edge of the membrane that they 
are hidden by the posterior ])art of the meatus ; if their 
presence is suspccttd. the iipturiud edge of a fme probe will 
atford conclnsi\-e e\-i(lencc. oi' a tiny spe(d< of moisturt' mav 
be seen on theiiiiiur part of the membrane. In a large number 
ot eases the former is uol a perhiration of the niembrana 
tymi)ani in the usually acci'pted sense of the word, for 
cicatricial tissue bin<ls down I'n' e-dges of the membranous 
]iortions ol the perforation to the inner tympanic wall and 
posleiior wall ot the adilus. so that piis from the antrum tlows 
dire(tly into the extmial meatus without actually entering 
the ca\-ity ol the middli' ear. 

The risk of injury and destruction of any link of the ossicular 
I licit! \aiies both with the duration and with the situation of 
llie perioral ion m the membrane one in front of or below 
'he hanille ol the malleus being comparati\-ely rarely accom- 
panied b\ ii, <],,-,i> ,,|- I ai ie> ol ilie ossiele■^. A jierforation 
ol aiiv duration situated in tin posttiior superior (iii.idiant 
is iiuaiiably ,lc( (nnpanic d by a carious liestincl ion of osseous 

.(....;...- .1 i _ , ^ t . . -. ■ -. 



'••M 



MiDDLii-i.AR ciiKiiSU >i ' I'rr I;.] 1 1 v 1. i)isi:.}si:s is/ 

joint, llie stapi'S itself, or l)olli the stajics and the louf^ jiroct'-s 
of tlie incus, bcin^ the j.arts ficcinintly affected. A ].eriora- 
tion of Shra]ineirs nier.iltnine. wiiieh lias exi>t((l lor even a 
comparatively short time, will be aeeomjianied by destruc- 
tion of the malleo-incudal joint ; witli a jurforation in this 
re^'ion wliieli lias I'xisted for some months or more the luad 
of the malleus and the iuxlv of the im us will In- more or less 
destroyed, aid in rare instance's, whi^rt' a long-standmg 
suppuration in this region has lu'cn cured, the malleus and 
incus \vill have liecoine ossified to^'etlur. In Fi^- -|'' \^ill 
be seen a diagrammatic represi'Utation of the frequency witli 



'.l I 




FIG. 46. TOT.\L PF.STRfrrlON OF MFMBR.VNE A.ND HANDLE 

OF MALLFCS (I.FFT). 

RM, Rimainder of malleus with a tikmirnt of tvinpanie iiirinbraiie 
attaehed ; .S, .stapes ; /. iimis ; ST, stapedius tenddn ; l-'R. Inraincn 
rotiiTidum ; /', proiiiontor\-. 

which v.irious parts of the ossicles are destroyed, in some 
cases of extensive destruction of Shrajmeirs memlnane the 
incus may be entirely destroyed. a,,d only the li.mdle ol the 
malleus left. A method exists of ascertaining wh.ether or 
not the ossicular chain is comjilete by gently stroking the 
drum with a line probe, when, if the ossicular chain is com- 
plete, it is felt, a friction sound is lu-ard ; if the chain is in- 
complete, the movement of the jirobe alone is teh. hut the 
tost is of trifling vahic 

When suppuration is profu.se a dro]) of pus may l>e fre- 
quently seen oozing from the- perforation and at limes a 
distinct pulsation is notudl in ilie exud.uion. TIu;. ph<uu- 



-i ^1 



m 



! 'U 



^5^ 



iiAXDbooK ()/■■ /jis/:.}sj:s ai- Tin- i:_u^ 



nun..ii has h.rn cmsianvd ..f sonu- iiuiHU-tancv as iiulicati.is 
liic iircsciicc (/f ('(iiiipliratidns. 

Quite fivqiu'iitly tile perf.,rati(,n is lu.t vi>il.i,.. ritluT „n 
a(T(mm .,i ,ts size ,„■ I„raiise it is so >ilnatr,l as n.,t tn 
come int.. VI. U-. I„ Mieh a ease tlie ear i.. ,f n.ressarv 
again carefully .Iri.,]. and an attempt nuul,. to draw 
soine disehai-e tlu-.nigli the- perf.,ration fnmi the nii.ldle 
'■ar. If this man.etivre i> suceessful. the site ,,f the pnhira- 
t>on IS easily leeat.-d. When the p.rhuati.ui i. not so 
disc(,veivd. inflation hy nirans (,f the catheter will give 
in the event of a small iXMloration a uhistliiig sound, and in 
the case of a larger on<' the ai- cmnvnt will strike directly 
on the ohserver's tympanic membrane through the ausculta- 
tory tube. 

Course.— Tlu> .-ourse of chronic otorrha-a cannot be said 
to tend towards spontaneous cure. Permanent spontaneous 
cessation of disrharge conies about in relativelv an extremely 
small proportion of cases. Cure can be obtained by careftil 
treatment in a fair number of the cases which come under 
«>i)servation ; a large ntunber. however, tend to continue or 
relapse, and of this large class few fail to exhibit complications 
at one time or another. 

The complications, to which reference will shortly be made 
may bo divi.led into th(,se which are o„lv hurtful so far as 
the organ of hearing its.-lf i> concerned, and tlio^e wldch, 
if left untreated, may sooner or later end fat.dlv. As will W 
seen after a consideration of the possible complications of the 
disease, no case ,,f .lis.diarge from the mi.ldle ear should be 
elt without careful an.l continuous treatment upon ordinary 
imes; and if a cure eann.,t be obtaimd in this way in no 
lustance should the patient be allowed to continu,. witlunit 
Jiaving the dang.rs of his position an,l the advantages 
"• '>'' 'I'TUvd fnr : npuative procedures elearlv placed b.fore 

JKK.vr.MK.M.— The treatment oi ehr.mic suppuration may 
iH' divided into altunpts to cure the discharge by means r,f 
.aitiM-pii.s or astringents, or l,y op.Talive nieasuivs. The 
i^Uei ci;e coiL^id^rLd. uiiii ilmr mdu atum^, on p. 190. ,1 scq. 



MiDDi.i: i:ai^ cinc(^xic si:ri'rj,\i rii-i: ni^i:.isr: 



i.sy 



C)])ini(ins arc larply dividcl as to tlu" relative advanta^'es 
1() he (Icrivfd from wet or dry trratiufiit ; Imt. speaking 
,m'iierally- the wet treatment, l.y wliieh is imderstood the use 
(if injections, combined with the ust- of lotions in the form 
(if (hojis. will as a rule give the more satisfactory results. 
The lotions wliich arc to he employed are gi\-en in the Ap])en- 
dix () to i(>. and arc to he jicrsevered in rci.;ularly for a con- 
sideral)le jH'riod. Wliichever is selected is to he employed 
with care, the main ])oint l)ein;4 to entirely free from discharge 
all parts within reach of the stream ; consequently sufficient 
force for this jnu-piise must be used, and the stream directed 
along the superior or ]X)sterior meatal walls, and the oar well 
dried aft(n-wards. These injections should be used at least 
thr(>e times a day. and the jiatient should be instructed to 
attach to the nozzle of his syringe a fine indiarubber tube, 
which is to be used as already described. 

As chronic sujiptirative otitis media is an extremely ui- 
tr.ictable dis(.'ase. it is well to change the lotion at intervals 
of 'rom lour to six weeks, until one h.as been found which 
seems to exercise a good influence on the disease, as is shown 
by the gradual cessation of the discharge and a healthy 
appi^arance of the parts. 

In every instance the prospect of cure by the use of anti- 
septics is greatly enhanced if all injections are done by a 
thoroughly competent person — either a well-trained nur.-,e 
or the medical man h.imself ; and it is largely due to the want 
of skill on the part of the individual v.ho is responsilik' for 
the syringing that so many cases will not yield to treatment. 

Of all the varieties of antisejitics used, biniodide or jier- 
chloride of mercury. i)oracic acid, and creolin and lysol are 
the mo'"e universally serviceable. 

After all n-rigations. it is of great importance that tlie 
nnddle ear ;.nd external meatus be left as dry as jiossilile. 

Occasional intkition oi the ear after syringing is to be 
advocated, as blowing out i>us from the middle ear into the 
meatus, and ^o « iiabling the antiseptic more easily to jjenc- 
trate into tlie deejier jiarts. An\- <m;d1 t,'rannlations or any 
signs (if ( iiole-teatdu.a will call lor ajipropriate treatnunt. 



''■■ 
^ I 



■I ^l 



( 1 

n 

'I 
ill 



I ! 



lOo 



II.IMHUIOK (II- l>ISi:.ISi:S Oh I III. I.AU 



ulii'l. uill 1h' [(Hiiul .lrscni)ed under llase ivsjKrtiv cum- 
I'lic .It idiis. 

AiiotluT valual.lc r<.rni of tivatnirnl li. s in tlir use of 
alcohol (Iroj,^ .m,l hyd. jhtox.. io voIunir> two m,- ih,-,, tini.-s 
daily. Thrse may. with a.lvantap.. W- ti.,,! aft,r nTiiiution 
Willi an anti>ri.tir solution and Mil.M'.inmt diAin^ ,',f t],,. 
in(at,i>. A wannr.i tcaspo.ai is ].ai;lv filird with thr Intinn. 
whicli i> tlun i.oniV(l into thr car. <;r is in>tillr,l hy nuan. 
of a mrdicmc .Iroppcr ; these remain in the ear foi" twentv 
"ininles. the hea.l hein^ placd with th. ear nn.ler attention 
"I'l'-nnost. •llusc ,,ntt;e may 1.. n.ed in eonjnnction with 
irrigations. Imt the ear is t(, he well dri,.l ,„it l.efniv and after 
they are emploved. 

Alcohol di-oi.s find their chief iiulicatioii in those cases in 
which ^Taniilation tissue tends to appear ; all <,mtt:u give the 
iHSt results when the destruction of the tympanic meml,rane 
IS extensive, winch enables these fhii.ls to search out the nooks 
and crannies of the middle vav and attic. 

The use of peroxide of hy<lr(,f;c.n twice or tliree times daily 
without usingr any other lotion, is a form of treatment uhic'h 
will treciuently give very goo.l results, nunv especially where 
■slight tendency to cholestcatoniatous generation is r^reseiit 
or the pus is very thick and tenacious. 

The use of sterilized I.oracic powder, or l.oracic and io.lo- 
l-nn mixed, may he freciueiitly employc'd with a.lvantage 
when the destruction ,.f the tympanic membrane is of .,^n- 
sideral,le extent, an.l may be considered contra-in.licatc.l 
when the perl.ualinn is .mall, and when it is situated high ni) 
\.uen powders are used they are to hv insufflated int., the 
ineatns once or twice daily h.r three days, and tlu^n removed 
by antiseptic syringing, and the ear thoroughly dried l^efoiv 
t >.■ I'owder IS agam insufflated. If this irrigation is not 
observed, the meatus tends to become occhuled with a mass 
of inspissated pus and boric acid powder. 

During the continuance of the local renu.lial measures 
general treatment inu..t not be neglected, a careful a.lminis- 
tration of tonics, attention t.» the digestive system and 
excrott;:y [anctiuiir, ii.t\jii^ ;i„ imp(ut;,,it bearhig on the 



li ': 



mii>I)I.i:-i:ar ciiuoxic sri>Pi'j:.i nii: jjisl.isi:s im 

pr(i,L;rcss cf tlic case. In cliiMr"!! Ilir use of cod-lixiT oil, 
(ir ]jri']i;ir,itiiiiis of malt, will attonl x'ciIiklM. .li'l. a. i! 
]iatirnts uli(» siilfcr willi adiiKiiil - ■•f^etation^ lluir r(ni..^.u 
iiiu^l lir con^iilcrt'd tlir ino^t iiii]>oitaiit piiliiiiinaiA' >t( p. 



Chronic Suppuration of tlie Tympanic Attic. 

Cliiiinic ^ii|i])urati()ii in this sitnatiim is iiCdt^niz ! l.\' tin' 
pn'sciicf of a jicrforation in S!iiai>n( ll's nuinhranr (Plate III.) 
to,L;(thci" with a history ot clironic discharges. Freciucntlv 
these ])erfoiati((ns are ])artially closed liy e])ithelial del)ris. 
and troni thein at times one or more small jiolypi may he seen 
protniding (Plate 111., Fig. lo). In order to confirm the diag- 
nosis tlu' bent end of a tuic metal i iobe may bo introduced 
throngh the jierforation. and bare bone sought for at the 
same time. Pi'iforations in this locality may iiave existed 
for a number of years with an exceedingly small amount of 
disturi)aiice to the hearing-power, and it is due to this tact 
tliat patients suffering from chronic disease of the attic are 
extreinth" loath to submit to ny ojieratix-e interference 
suggt^sted for the cure of the discharge. The parts of the 
ossicles which are destroyed in attic suppuration are the 
whole, or part, of the head of the malleus, the body of the 
incus, and its short process. Or the joint between the malleus 
and incus may be disorganized, with destruction of the 
articidar cartilages. Chronic supjiuration of the attic is 
extremely intractable. This is due to the size of tlu^ opening, 
and to the fact that, although it is ajiparently in the most 
dependent part, yet jnis may be lodged in yarious membranous 
compartments within, from which free drainage is impossible. 
The disease does not often spread downwards into the cayum 
tj-mpani. as all the interstices through which pus would haye 
passed are closed by the chronic inflammatory condition of the 
nuicous membrane. 

Kxtension of the disease towards and into the external 
canal is occasionally found ; if so. the lesion is one of the ex- 
ternal semicircular canal, and will in most cases be confined 

to *!'i.'!t !>,'irt of tl::^ InVi'.'riTTth. se. that excellent heriri'.!!.' is not 

incompatible with this condition. 

II 



■*i 



i 



162 



HANDllOOK OF VISEASLS OF THE F.Aj 



m , 



liiil 



kl'l 



Pathological perforations of Shrapnell's membrane require 
to he distinguished from anatomical deficiencies. These 
latter have no significance. 1)eing merely errors of develop- 
ment. The pathological perforation is distinguishable by 
the redness of the surrounding tissues, the presence of detritus 
or pus in. or the passage of pus through, the opening. 

TKiiAT.MENT.— The nozzle of a Hartmann's cannula should 
be introduced into the ])erf()ration with the aid of reflected 
light, and the cavity of thi' attic thoroughly washed out witli 
an antiseptic solution. Ij'sol, carbolic acid 2 per cent, solution. 




^Ui. 47. — rKoKi:ssoK hak imann >> at:ic can.mi.a with i'.all 

SVKlNC.l. ATTACIIin. 



bnrie acid solution, or w(\d< eorrosi\-c sublimate luiiig idl 
r(|ual!y < ttie.iiioiis. Tlic ii atinent nmst bi' carried out 
carelully tor many weeks, ami llie lot ion^ changed fairly often, 
ll no diminution in tlie dix harge od urs. operatixc jirocednns 
siiotdd be undertaken. These ma\' be (i) an enlargement ol 
tile o])ening by cutting awav the out' r attic w , ill with Ki. nine's 
forceps : (2) ossiculectomy ; (3) the jiaitial mastoid operation. 
'1 he clH)i(.e of these procedure-- \^ ill \,ii"\' aceoriliiig to the 
experience of the oper.itor (see ( )peiation>). 

.\s alternative treatment the surgeon may u\e-li through 



MiDULi.-EAR ciiuoMc si'ppuh'ATi ii: dis!:asi:s I. .J 

the oar and attic fmin tlio Eustachian IuIh'. using cither 
normal saline sohiti. ii cni])l()\ing for this purpose a syringe 
and Eustacliian cathiter. or tiie izal oil treatinenl. recoin- 
mended earlier, may lie tried. 



Complications of Otitis Media Suppurativa Chronica. 

ICczenia of the meatus, vertigo, nystagmus, sickness, pain, 
lieaihiclie. tinnitus, granulations and jxilypus, cholesteatoma, 
necrosis of the o.ssidcs. necrosis of the tcm}H)ral hone, necrosis 
of the ]al)yrinth. extt>rnal and internal tlsttihe. contraction of 
tlie meatus, facial jiaralysis. su])])m-ati()n witliin the hdiyiinth, 
lateral sintis i)y;L'mia. extradural and intradur^d ahscess. 
meningitis, cerebral aliscess. and cerel)ellar abscess. 

Vertigo on Syringing, and Lateral Nystagmus.- When a 
patient complains of xirtigo on syringing the ear. tlu jaacti- 
tioner should make incpiiries as to whether the objects in the 
room gyrate constantly in the same direction, or if the patient 
has a teuflency to fall in any narticular direction. To obtain 
dehnite information upon the vertiginous comphcation. it 
is necessary that the practitioner himself should syringe the 
ear : the solution, to make the test more reliable, should be a 
little colder or warmer than usual. If the disturbance of 
e(piilil)rium is general, it may be attributed to pressure on the 
footplate of the stajies ; if. on the ( ontrary. the objects ha\-e 
a tendency to rotate in the liori/ontal plane, or if the patient 
trnds to iall towards the side wliic h is beir.g syringed, tin 
lision i> ]irob;ibly in the region of the external s> inicircular 
I anal. 'Ihis is cdirdborated if Literal nyst.ignms can b( 
"li( ited. the oscillations in this i ase iuing extr(nielv small 
and transitory in (haiact.r as compared with those found 
in meningitis and ciiebellar abscess ; at times the vii)r.itory 
mo\-eiiient IS e\ident in an acute exacerbation of a chronic 
otoiiliiea. '1 111 se cffrcts are (ause<l eitlnr by an iiosion of 
till bony semicircul.ir canal and the eouseijucnt exposure of 
tht iiiemliranous canal to the Iml oi (old lotion ; or when 
iiyst.iginus, due to the car lesion, is present alone and is not 
eluiiid b_\ syiinging. it is due to an nstiths ext< nding mw rds 



il 



I ''4 



JI.IXDUOOK OF DISFASLS OF TlIF F.AR 



from the ili r or aditus 'nicli ronipivss(>s soiiiowhat tlie canal. 
'I'lic iliitficncc noted on s\Tin,!;inj; Ix'twccn a lesion of the bony 
external canal and a jierforation into it or the volilmle is 
that in l!ie latter the ])a1ients tend to fall awav from the side 
alfccted. (I'or fuither i>articulars si ]>. jf).)). 

Granulation Tissue and Polypus. Aural I'olypi art < <.m- 
jiosed in e\er\- instance of ordinary, and later, oi or^^'anized 
urannlat ion ti>sue. and aiis<> either from ulcers oi the mucosa 
or ai'e (xulierant Luanulations siirintjinij from diseased hone. 



Ili 




I Ki. 48. - .\ri<.\i. I'di.vi'cs I'KoiKt DIM. 1 KoM ^n:.\T^;b. 



The ]M-esen(e of jiolypus in the oar may commonly he assumed 
if the di>charije is at times tinp'd with lilood. Tiiev are not 
infie(|ui n! 1\' ( ,1-^t oil' sponlaneotisly. a ( ure jiiohalilv due to 
a Iwi-'ting ol the |iedicle nr to its degeneration. 1 hey may 
he rem(i\i d dming s\-rin,L;ing. more especiallv vnIicu an india- 
ruhhi I luhi' i> used, and its 1 nd lia> lieen introduced In yond 
tile grow 111. I'dKpi o((a-iouall\' cause a series of s\inplonis 
(juite peculiar to liiemsel\( ■^ : m tiu'se cases, touching the 
]ioh-]ins ma\' alone ,i;i\e 1 ise tot lu most se\-ere vertigo, ending 
Hi mil on-~( inii^nev-.. whiNl n\'^1.e;i!n> .lud •^ii I^ne^^ are some- 
timi> llie n.■^uh ol A\\\ aji|ihc,itinn. ! hi'^e |>()i\]ii ari^e ui 



MIDDLE-EAR CHROXIC SUPPURATIVE DISEASES 165 



the aditus in connection, or conjunction, with a fistulous 
opening in the bony external semicircular canal. At other 
times, from their size, they may obstruct the outflow of ])us 
from the ear. and so set up a state of septic auto-into.xii-ation. 
Tlie polypus nuist lu' distinguished fnnn a red and bulging 
memi)rane and from the lining membrane of the tympanum, 
(■s|u (ially tliat which cf)vers the promontory, when red and 
tliickt'ned and of a granular appearance ; it also re(iiiircs to 
be cH>tinguis]icd in rare instances from a red au<l smooth 
foreign l)ody. A ]iolyj)us. when entiri'lv within the ear. 
can lie distinguished from ■' Indging memlirane liy the fact 
that tile latter is in acite condition, win reas a ]iolvi>us is 
comparatively rarely found in an acute otitis meilia. and by 
the fact that a polypu:, can be fretdy moved about iiy a ])rol)e. 
anil l)y the passage of the jirolit' all round it ; further, if it 
is soft, it usually bleeds very freely, and when prtssed upon 
does not give a sense of resi^^tance. as does the promontory, 
wiiereas a foreign body will usually !>(• hard. Polypi at times 
project lieyond the oritice of the t'.xternal meatus, growing 
to a large si/,e. Tliis condition is liecoming much ranT in 
ci\ili/,ed countries on account of the greater appreciation of 
the gravity of discharge from the ear. Small jiolvpoid 
growths projt'cting through .Shrapntll's iiu inlirane appear as 
small red masses hanging down aliove tin handle. 1 hey 
occasionally arise at tiie edge of a listula in the canal, and 
tli'U will be found att.iclud to tiie wall of tlie meatus when 
an alt<nipt i- m.ide to ]ia>s the ]irobe rouml them. 

l'.\rn()i.()GV .\.\i> lli.^roi.oc.v. -An aural polypus has its 
origin in a Initton of gramilatioii tissue, which is alnioNt m- 
variablv tlie outiome ol siii>piirative inllammation. It i>. 
in but. ihe ' inoud tl ^h ' of 0111 jiieili 1 i^xus. The button 
ot -lannl.ition tissue likes on exuberant ^rowlh; hlood- 

\ I ^^eK develop within it ; il;-> suifiee become-, i.^iailn.ljlv 

'loiiieil with a l,iy<'i' ol epiihrlium ^euei.dly ^(lu.imoiis. 
>omi tunes i.ihhiiK towards the euhimn.ir t\'jM-. espreially 
it 111' polypus becomes inanched am! its snil.ice niegular 
I ln' Ititme ( hangi s which take plaee aii m.iteiiallv inthi- 
'■nci d li\ the peiicid o((ii|iied W its ijiouih. Ihe last 



■I 



■ I 

m 



166 HANDBOOK OF DISEASES OF THE EAR 

alteration in the histological structure after the develop- 
ment of the bloodvessels is the conversion of the whole 
mass l.y gradual stages into a soft ril)roma. llu' leucocytes 
l)econiing >i)indU-shai)ed cills. A secondary contraction of 
ihv older tissues nov.- takis place, and a lirmer fibrous struc- 
ture is atlai-.ied. which grachudly ].r()cceds until the whole 
]M)lypus is a small i.ednnculated hln'oma. Should ihe l)lood- 
suiii>ly of llic jiolypus W frer. thr growth may <'ither remain 
a iibroma or take on tlu' characters of an angio-filn-oma l)y 
(vcssivc development of its bloo.l vessels. If. on the other 
hand, tile bl(i<idv.-,e]> are insufficient to supj.ly nourishment 
to the mas-., nnicdid degeneration i.d^es i>]ace. the librous 
tissue apparently be( ondng resolved by imicoid degeneration, 
while the connect ive-tissut deinents lorm the beautilul 
branching stellat.' cell> characteristic of a myxoma, and the 
growth i> now either a myxo-libroma or a i>uie myxoma. 

iKic.viMKNT oi Aik.m" Poi.vi'I.— Tile treatment of aural 
]H)lypi must not intert\>ri' with the treatment of the disease 
,,1 which thev art a ccunpli. .iti.m. If the polyin are small, 
and really not more than slightly exuberant granulations, 
no oiKrativ.' measures are usually necessary. If. however, 
they are ..f appreciable size, the sooner such growths are 
destriived tlie better. 

N,."np. ration b.v th. removal of aural j.olyia shouhl be 
cmm.'iu.d mitil . aietul antisep.tic ]Mecautions haxe been 
takdi. U thJH lie done no ill-elteeis will a.True. A thorough 
amis, ptic inigation at lh.' time ol oj-eration will be sufhcient. 
l,„t a piex i.,us ( leansmg and ].aekmg of the < anal with anti 
sejitK g.m/.eisimi. h to be desir<(l. should time and oi'i'<""iii".v 
prvmit'^ I'olvpi mav be removed in a large number oi <ases 
„„,1,, eoc.nne .malgesia ; but it the patient is mrvotis. or .1 
t,,ne|nng the polvpi gives n^r to unpleasant symptoms, ivsort 
should l>e Ii.mI to ^;< iieial .ma-thesia. 

In most ( ,ises the destrueiK.u of the i^olvpi IS a( complislied 
.■iili, 1 bv means ol a -mall mi. ire. oi bv a . ur-Me. lhonL;li t lie 
x,,lual.!e .ind <uiatue i.ou,rs ol < aust k s and a.stimgents 
inn I not be loii^otteii 

II ii„. ^n.iie IS used, the mo-t (or em. lit mstrument i-> 



MIDDLE-EAR CHRONIC SUPPURATIVE DISEASES :t7 

Griibor's. It is threaded with fine wire, and the \ocyrJ. 
regulated according to the size of the speeuhim used . it can 
Zi conveniently be gauged by tightening tl^^ -e W 
the tip <.f the speculum next smaller m sue. The loop is 
1 bent at almist right angles to the shaft of the sna^ and 
,,mly introduced ron.ltl.l.lyP^^^ 
meatus as possil)le. 1 he snare is . Km iv s K„t nther 

,„,^^,,. ,,,t to cut entirely through the polypus, but ra r^ 
.,.„ a iirm hold ,s ob,.,ned. to pull off the growth i,y^jduup 
,ug. thus making sure of obtammg the whole of it. Bhcdm^ 
: Sometimes free, but can be controlled bv pugging th 
gauze after the meatus has been well syringed out . th a 
strong antiseptic solution, as 5 P- eent. carb<.lic acid or 
T in T 000 hvd. iierchlor. , 

wJ:::noLmorrhage occurs, or after it has bceii checked 
the stump of the growth should be touched with 1 m, t . H rn 
Pcrchlor.. or some similar caustic astringent 

Polypi may also be removed by means of a blunt curette. 
If U e urette is use.l. it should be passed to the base of the 
^-owth. withm the tympanum, if that is the place of ong n, 
r.r if the meatal wall be the site of growth, then the cmette 
nmst be kept as closely applied to the meatus as is poss^ble^ 
The pedicle, or base of the growth, is to be pressed iundy 
agauL the meatal wall, and divided by sharply withdravnng 
h instnuuent. kcpuig it pressed firmly against the meatus 
This is ceuamly the more rapid method, and ,s also the mo, 
easily used and is more efhcac.ous .-1-" 1-i-nned in. e^ 
general aiuesthesia. but without it is slightly moie pamful 

than removal l)y suare. 1 1 1 , ,ini,r 

After the growth has been cleared away and bleedmg 

arrested, the site from which .b.e polypus spra, ;. toge^ her 

,,U1> any Mualler polyp, whuh tnay have been brought o 

!|;,a,,da,e,oo'maUfor,e,m>val.shouldb, ,<n.<d.edw,th 
chronuc acd fused on the e.ul of a probe, or trichloracetic 

'" l!',l,e patient refuse tosubmit toany op.Tation. the polypus 
,nay be .Istrnved by tncans of chn.nnc acd. a sl-.w and souie- 
,,nw-ess, except m tlie ease ot small gn.wtlis. 



i 



..a:.. 



ir.8 



H.iXDnOOK OF DISEASES OE THE EAR 



This nictlind of dtstroying polyi)oi(l j^nowlhs. as practised by 
PolitztT. consists in the ajiplication of a single crystal of 
clironiic acid lo the ]!olv]nis. The crystal, if the j^'rowth be 
small, will sonidinu s canse a complete sphacelns of it. If this 
fa\durabK' rcsnlt docs not hai)]icn. when the slough sej)arates 
the ]iroc( ss is rrjicatcd until comjilctc destruction is obtaini'd. 
It is always ^\^ll to rfm( inber that in soft and pedunculated 
polyjii a vigorous use of the syringi^ will not infrefjuently 
ruj)tui'e the connection of the growth. A \-ery favourite 
metlioil (it distroying granulation tissue and smalki" growths 
is the u^e of alcohol; anv of the lotions in the .Vjipendix 17 
to _'o uiav be em]ilo\'ed in the hjrm of drojis ; 10 to _'o minims 
should be poured into a prexioti^ly warmed teaspoon, and then 
allowed to tlow into the affected ear. whilst the head is inclined 
to tlu' opjiosite shoulder. These drops should be allowed 
to remain in the eai" for about t\st'nt\' minutes, reinating the 
trt'atnu'ut three or four times daily after syringuig and drying 
the meatus. 

Cholesteatoma-- P.\iii<)I.(igx. - - ( holesteaiiuua is an ex- 
aggt ration ol the nornuil des(]uamation c<instantly ]irocetiling 
Irom all e]iithelial surl.ices. Th'' nuicous niend)rane ol the 
ndddle ear ha\ing at lust become sonu'what epideruii/.ed. 
the dead epithelial cells which should be cast off are retained 
in then' jilace b\' the presence of retained secri'tion or b\' some 
(ilher lorni ol ohstiui tion ; eec cuti-ic jiressure is thus gradually 
exeited li\- this inert and (dmt.intly uicreasing mass, which 
in (duise (il time obliterates tlie ]iapill,'e nornrilh' bnnid m 
the rete. and redm rs the whole ejiitlt ruu/.ed nnicous smiaec 
to a mt inbrane ol exti'eme Iriiuily- and one ha\ ing a p( r\'ei led 
iunciion, 'I his jialhological pKK e^s ui\anabl\- < ummences 
in the upper |i,irl ol Ihe l\iiipame ia\ity llial is lo --ax'. in 
the allii but il m.l\' ixlend o\el the whole iil llie iulcrnal 
w.dl ol llie Ixnipanum, and will pei-.i-.t aliir the iimo\',U 
ol all ob>-l 1 net ion ; the e.sleiisKin ma\' |iio(ti(l to sir h .u\ 

exli III ill. It It !U\o|\( s. bisldis the atlle. I he wlloii nl ihc 

aiitium. and nia\- jkui i.ale dUe ol the Ihs^.l' ol the skull. 

as well .IS holliiw (lilt the whole ol llie mastoid ]ilni(s-,. (ir 

e\iii liie imui ear .imi j (.'irons poiinHi iiseii . liie jioiies 



MIDDLE-EAR CHRONIC SUPPURATIVE DISEASES ibg 

arc alisorbcd in consequence of the pressure as an effect 
(if the ]in)cess. The cholfsteatoniatons fonnation does not 
inwide osseous tissue after the nuinner of a niahgnant 
f^rowth. 

Cliolisteatoma almost invariably occurs as the result of 
chronic sujipuration in the middle ear. though some ol)- 



A 



il 




# 



il 



m 



FIG. 4<l.— \TKV l;,\ 11 NMVi: UlOl.r.sTliATKMA Ol l-Ar<. ( AISING 
COMlT.l II MSdKI'l IIIN Ol' INTKRNAI. PwXK. i 'I'l: Nl N<V IP lAllKAl. 
SIMS (/. s.l, ANTI ( ACslNc. IHATII I'V I'V.IMIA. 



si'i\(is 111, lint, iin til, It it niav 1h' )iiiinaiy. Cases certainly 
do i\i>l 111 winch .L sin.di . Ik.!. ■>lratonia1 ini;^ mass is ol)- 
>( rwd |i(ii,Mtli ;in iiit,i(t mmilii .in,i tvinpani. hut usually 
a lii--l(ii\ (it imiiii r -^upiuii.it ion can lie dlit.uned, and a heliet 

III iiiiviii.ii ( i n Mt -.i I (iM 'il i.n C'lt ' ioj iii.t: ;: ::i ■.'.;:;;:■:;: j ::;'.;: :i;ri 



liil 



I70 IIAXDBOOK OF DISEASES OF THE EAR 

or existing suitjniration in the middle ear is not hy any means 
universally held. Under th(^ niieroscope the tumour consists 
of laminated laytTS of epithelium, amongst which eholesterin 
crystals are to l)e found. 

The ol>i((tive appearances uf this condition consist, in the 
severer cases, of a yellowish adherent mass within tlu' tym- 
panum, extending at tinus to the det'per parts of the external 
meatxis ; the material, when removed l)y the syringe or forcei)S, 
is fomid to consist of dead epithelium, more or less discolomi'd. 
the lower layers being extremely adheri'ut to the underlying 
tissues, though in ,-;"! te case.i all except tlie most recently- 
formed layer come away very easily. In tlie less advanced 
cases the inner wall of the tympaimm. instead of being of a 
pink or yellowish colour, is white and rough, and attentpts 
to remove this adherent material cause pain and are often 
attended by slight l)leed)ng. 

Tke.Vi.ment. — The essential to be aimed ;d in the 'tne of 
this condition being to ol)tain alisolute dryness, it became 
m'cessary to consider careftdly whether treatment with alcohol 
is calculated to obtain such a restdt. The reasons winch 
militate against this form of treatment are. that in the hist 
l)lace. alcohol rarely of itself, however carebilly ap])lied. 
obtains a cure ; and the second is that alcohol evaporates less 
ri-;idily than it al)^<orl)s water, and that tmless the alcohol be 
al)Solutely absolute, or as marly so as can be commercially 
olitained, it contains alrt ady a certain amount of water, 
which must l>c left liehind, were it possil)k' that the alcohol 
were I'u'irely cvaixuated. It secined necessary, lluiefore. 
to s.'ck further. Tlu' ouly Ihnd which apiarmlly tiJiillrd 
the requir ■nunl was ether, and after xunr yens dt trial etlu'r 
has in my liands ;ipi),ircinlv acted in the way in whieb it was 
liopcil it would. I'Jli.T. like .ilcdlioi, causis a certain amount 
of local di->((imlort. Init tlir luniiing and jiain are l<ss in 
inlensitv and more (A'anrsct-in . Tin- im tluid ot ap])lying 
etlier is to take a, pidb>' aimed with (oitoii wooi s;itui.itrd 
witli itlirr. and to will swab out the discas. -area. Wlicn this 
is ildii.' hv the iHi (lical man liimself, very raiud dryini; ( an lie 
olitam.d l>y gently blowing un(. thi' ear wUli a rublier b.ig 



MIDDLE-EAR CHRONIC SUPPURATIVE DISEASES i/t 

(Pulitzer's). The patients tliemselves ran easily carry nut 
this treatment, but they shoukl be seen at intervals for the 
surgeon to remove any <lry fragments of the mass wliieh have 
not come away on tlie swalis. If the disease is i-xtensive, 
and there is reason to su>]>( ci that the antrum is involved, it 
will be necessary that thi> ea\ity should Ix' oiH^ncd in order 
to treat the morbid changes effei lively, and without mi- 
necessary dclav. In cases which ]'rcsent -mailer aicas ot 
disease, all the flakes of tissue shotdd b' removed by m-ans 
of the curettt' or syringe ; under wliiidi circuiustaiu es an anti- 
septic solution should i)e invariably used for irrigation. It is 




PIG. 50. niAOK.VM MIOWINC Till-: TWO I.AKGKR OSSKLKS Sll.XniCD TO 

SHOW TIM. MORI rslAL SI I IS OF CAI'.Il'S. 

I anil 2. '1 lie lUdst edniiiu.u : 3 and .), the ne.\t, the litjhtly shaded 
parts resihtini; the longest ; .!/•', articular faeets. 

often necissary to use solvents to loosen and dissolve tlie 
epithelium for some time before it is possil)le to clear av.-.iy 
completely all tlie dead .md diseased tissue. Unless the ]>al leut 
is un('er close observation there is a theoretical objection to 
the use of a(iue:ius solutions in the tri'atmen' oi this disease, 
whether in at1emi)ting to icmove the mass or t(» sotten it, 
and a case is on recoiil in wlii' h a fatal result is said to have 
lollowed. 'ibe reason of this is said to be that the vdioleslea- 
tomatous mass imbilies water Ireely. and in conseciuence swells. 
Sinci' the mass contains a large number of micro-organisms. 
tlu V all' thus forced into the surrouiuliiig tissues, and septic 



u 



ri 



-ill 



(1 



■If I 



172 



iLixDnooK or dishashs of the far 



al)snrption follows. Of all thr solvents papainc and salicylic 
aciil ail' the most iistful. and may be used t-ither in solution or 
as a paste (scf Appendix); whilst for the pm-pose of irrij^ation 
Weak >ohitions of loiinalin or ]icrehloride of mercury form 
the Ix'St tlnids ; thr preliminary use of peroxide of hydrogen 
is often extrnnely valnahle. This pre])aration. of the str(>ngth 
ot lo to _'o \-olnmes. may also be used with great efficacy 
after a soK-cnt has been used for a week or so. It will then 
bring away large (juanlities of material, or loosen them suffi- 
ciently to allow ol their removal iiv syringe. The various 
l>astt'S are employed in the form of jiellets. which are ju'essed 
into any recesses affected, or so aiijilied as to i)e in apposition 
with the choloteatomatous matrix. The ear is cleansed 




ir^ 




^'k 





riG. ; I, - Nr:cRO<^is of the l.\bvri\tu. 

a, Corlilen ; //. one sriuu irmlar ( aiKil ; c and (/, vcstilnilc, internal 

aiuHtoiy meatus, and seniieiruilar canals, seen Ironi Ixjth sides. 

after an interval, which, varies from a half to one week, and 
a Iresh ajijilication made. 

Necrosis of the Ossicles. The signillcance of this condition 
is dealt with elsewher'.'. The following perioral ions of the 
membrane are those more nsuall\- assoeiated with this com- 
plication : Perbiiation in Sliraimell's membrane, and in the 
posterior superioi' (|uadrant. and cases of complete or extensive 
destrui t ion ot the drum. In order to deteit a i.ecrosed ossicle, 
Use Is made ot the i nd ol a line probe bent at an angle of izo\ 
the uplmncd poition being about , ;, iru h in length. Tue most 
suitable ])i(ib<' lor this examin.ition is llaitmamis. This 
instrniiu lit is introduced through the peilor.ition in the 
direction ol the In ad ol the malleus, and if necrosis is jircsi'nt 
a line grating will be lell by the txamiiier and lii'ard by the 

patlelll. 



1 



MlDDLli-l-AU CllLilMC SmTRAllM. DlSl.ASl.S ■ 7.1 

Necrosis of the Temporal Bone. Tliis comiilicatioii is inon- 
frc(ivirnt in rliildnii. ami iN nl' inlinitcly i^TfattT rarity iliiiu 
necrosis of \\\v ossicles. Necrosed |iiec<'S of h<mv ol any si/.c, 
usually Mac-Jv on the >nrfa(-e. may partly or entiiely occlnde 
llie external meatus. They an- readily detecteil iiy the 
jirohe. and may consist of a p )rtion ol any jiart ol the temporal 
hone, and \m'\ in size from thin Hakes to lai};e irregular 
masses ; in a fair nund)er of in>tance>. and these (ommonly 




av. 



FIG. 53. OL TF.R SURFACE OF TFMPO.iAL BONF. OF A FOIK- Vi: AK-OLD 

CHILD, SHOWINC, NFCRQSIS OVI K TIIF SITK OF MASTOHl AMKCM. 

A', .\rea of ncivosis, consistiim: of cxtrnial antral wall ; GC , .lileiinid 
ia\it\- ; 1-0. fenestra inalis. 

in adnlts. a sequeslnini has heen fonnd of part or the \vhol(- 
of the osseous labyrinth. 

Necrosis of the temporal bone diMnands tiiore j.rompt 
removal than does necrosed bone in most other parts of the 
body, and it is usually reniovt'd by means of the openin;,' 
made for the radical mastoid operation. The oi)eration is 
more imperative if the bone lies deeply and involves the 
petrous portion of the temiioral bone, for the imjiortant 
vela1ion^,hip that the hiternal jugular vein and mternal ( arotui 



■■»»^ 



■■'\ 



1\ 



1:1 



171 



ll.l\bliOi)K Ol- DISEASES OE EJIE EAR 



h^ 



artiry Ixar lo the hihyrinth iim>t he Ixirnc in iniiid. Forniciiy. 
it was aih'isid lo arcuiiipli^li the ifiniA-.il df small ilakcs of 
(liad lidiir liy iiK ans oi tin- instillation of dilute hydrochloric, 
acid, 'lliis. ho\\(\-ir. is a ttdious. unsatisfactory, and some- 
what un^ur^^'ica' jirocedmc and should not be resorti'd to 
unliss under \ery exceptional circumstances. 

'1 Ih> ])resence ol necrosed hone in the middh' tar or tympanic 
cavity, or elsewhere in this rej^ion. becomes imniediately 
a proper indication for the performance ot the radical opt'ra- 
ti(Mi. These se(iuestra should not be remowd througli the 
external nuatus. as it is not possible to be sure that in txtract- 
ing them through the meatus some large and important 
structuri' may not be injured, as. for instaTice. tlu' bulb of the 
jugular win. The radical operation is the proper surgical 
procedure. 

External and Internal Fistulae.^-External ilstuls arc usually 
found close behind the auricle, and lead down to the ca\-ity 
of a chronic abscess in tlu' mastoitl. Fistulae in the external 
auditory meatus are lound in tlu' roof and posterior wall. 
Both these varieties of listuhe are due to the rupture and sub- 
sequent discharge of an absce; s situated within the mastoid, 
and altlKHigh fistulne are not of themselves directly dangerous 
to life, yet they should always be attended to. as the cavities 
may become infected with chronic tuberculous disease, and 
result 111 extensive areas of disease. When m the roof of the 
meatus they lead into those cells which have i)een described 
as the • border cells.' lying external to tlu' attic ; whilst tistul;e 
in the posterior wall lea<l either directly into the antrum or 
into one of the large cells in the mastoid. 

ihe Ireatment of these cases, with the e.xceiition of sinuses 
ill the roof of the external meatus, is the radical operation. 
When the sinus is in the roof, with an intact meinbrana 
tymi)ani and good hearing, a cure may at times I)e obtained 
by an energetic use of the curette without external o]ieralion, 
or the ])erl()rinaiice iA an incomptlete mastoid oi)iration ; the 
removal of the disease without oi)eniiig the antrum may 
result in t om]>lete lu ahng. 

Contraction of the Meatus— Whether this be membranous 



MiDDi.i: i.AU ciiKosic sr PIT h'ATi V i: i>isi:.isi-:s 175 

— thai is to sav, cicatricial— or Nvhcthcr it be <luc to I ony 
outgrowth— exostosis or liypcrostosis- it Ix'comc:. imperative 
UuLt a ra.lieal operation >houl(l he done within a reasonable 
,„ne. .specially if there be a discharge wldch i> at all hindered 
in Its escaiie by the contracted condition. Membranous 
stenosis of the external meatus is brought alnmt V)y an m- 
llaniniatory exudation witliin its wall, wliich, when converted 
uito fibrous ti^Nue. results m a circular contraction of the canal. 

Hyperostosis, or a bony outgrowth, may be due to the U'rita- 
tion of the discharge, or it may be coincidence. 

Facial Paralysis. -Facial paralysis, or Bell's palsy, is a 
complication whicii mav occur either in acute or chrome 
disease of the middle ear. So long ago as 1872 Sir \\ illiam 
Dalby pointed out that those cases of facial paralysis said to 
have followed exposure to a draught were freciuenlly due to 
an acute median otitis, the pain of which was so >hght and 
evanescent as to have been quite overlooked both by patient 

and physician. 

In acute suppuration of the middle ear, cspeciahy m children, 
paralysis of the face on the same side may super%-ene, whicii 
will get quite .veil after the otorrhoea has been cured, though 
perhaps not immediately ; in a large number of cases the use 
of the galvanic current will be necessary. The nerve, in those 
cases of paralysis which complicate acute disease of the middle 
car. is compressed within the bony tube by inflammatory 
products, due to an exter.Mon of inflammation from the 
mucous memlM-ane lining the tympanum to the neurilemma 
and to the periosteal lining of the Fallopian canal, by means 
of a perforation frequently found in the wall of the canal jii^t 
at the point where the nerve passes above the fenestra ovalis 

A facial paralvsis in chronic suppurative disease of the 
middle ear is a thing of vastly different import, and has a 
much more serious significance. It invariably indicates 
disease of some i-art of the temporal bene, and not infre- 
quently necrosis of the labvrinth ; the paralysis is an indicatK.n 
for the performance witliout delay of the radical mastoid 
oneration. and in cases of tuberculous disease signities an 
extension of the malady. It may occur as a central lesion, 



hi 



li 



1 70 



J/AMUHlOIx Ol- />ISi:.lS/:S ()!■ nil: EAIi 



<n- a1 any rate as a icMdii iidt due to any inicrlnvncc el tlio 
nnvo in their iiassa,i;v thron.i^li ili,' t. mpoial liouc In sn, li 
cases llicre will lie (,tlur induatii.n- in i^uidc ih,- sur,^e,,ii i,, 
a (-(iri-tct estimate nl it,-, si,L;iiilii'ance. 



Erosion of the Internal Carotid Artery. 

'1 Ii!> laiv cniiipliiatKiii IN nstially due td d, .mut i\.' iileera- 
iKin ariMn,!^ in tlie .-(lurse (.1 riiinni( suppui aliw nii.ldle-ear 
disease. It lias. \uw,\,x. (.(rasi(,nally lieeii ni.ortid as 
liavin- oceiirnd in rliildivii in uIkmii tli.ie lia> luvn no 
I'levious intimation ,,! any disease (,t the ear. altli,in,L;li it is 
inipiissible to avoid the suspicion that it was due to the lufon- 
menlioned cause. In >ucli a case the patient will have a 
sudden li;emonlia,i,'e from the nose, mouth, and ear. uhieh may 
\'i- imniediately fatal, or may prove so hy a iv, nnvnce ol ||,e 
ll.'emoll liaise e\-en helore assist. line (ail he olilailled. P(i>t- 
mortc 111 examination shows that the ulidative pro,-es> has 
ill its course ero(hd the arterial w.ill. 

1ki;.\imi;m, The treatnunt must '.e diieei.d primanlv 
to stoppiii- the h.L'moiTlia,:;e. and se,„iidarily to the piv- 
vcntion of it> adinvnce. Il th,. h;emon hap'is very seveiv 
and is not coninilled |,\- p,vs,uie ,,n the iiit ' nalCaroiid 
artery, the lust line ..f Heatm.nt consists iu the h-atioii uf 
the .uimion carotid artery ,md the p.rlormance ol th,' radical 
mastoid oiieratKiU. All , arioiis lH,iie is to 1„. ivnM,\v<|. and 
the eavilv thor,,iiMhl\- , haus, ,1 unh a \eiy strong aiitis, pi ,.•. 
as ad\is.d on p. .;i,, ; a plu- ol simh/.,,! "|„,,,swa\ is u^. .1 to 
Sfal up and I ompr, ss ihr ail. ly in its houy eanal. it the \, s^.I 
can lie 1. ucheil. 



Haemorrhage from the Jugular Bulb. 

W hen h.iMiioirha,i^e oeeuis ir ihis situation it ma\- l.e from 
ail uKeialivc process erodinj,' tlu' e.\t. mal uail of ih,. h,dl, ui a 
similar niamier to that w!ii(h has pisl heeii ailudMl to „, ih,. 
case of the uiierr.al carotid o, n may h,. ,lif loth, loii;; wall 
of tlie vis.si I l.eiiii; piiiH 1, 11. d .im 111;; incision (.t th,- m. nilirana 
".vnipani. In lai. mstaii(,.s Ih. l.oiiy i.ioteeli,,u all.n.h.l t,. 



MIDDI.F.-F.AR CIIROXIC ST I'Prh'.i T{ \T. nfSi:ASr.S [77 

this ]-iortion of the juguL-ir is :it)sc'nt. and tlu- win Ucs just 
Inhind tht' nnicoiis ini'inl)rane of the jiostorior and inferior 
imri (if the iniu r wall of the tympanum. In sucli instanees 
the surj^jion mifjiht notiee a pulsatory movement conveytd 
to tile memhrana tynijiani. or even visihle throuf^di it. and 
probably also a bluish relle.\ in the posterior inferior rjuadrant 
ot the membrane. From \vhiehe\-er ratise the h.-emorrhage 
arises, cantul and deep ])lugging under ])r()]ier antiseptic 
]>r. ( atitions will allow liealin;,' to take jilaet' in the wall of the 
Vessel. Should the h.'LMnorrha^'e be due to ulceration, anti- 
septic- irri;,'ation, t\\n while luemorrhage is takin;,' place, 
should l)e employed. Ihre. as in the former case, rest in the 
ricumbfut posit iou and absolu'e ([uiet are to be enjoined on 
the ]>atient. In the eviiit ol failure of thesi' measures, the 
sinus should be e.\]iosed and comiiressed ^-'th a l>luf,'. as 
descrijied lielore. and it may evin be necessary also to lii,'ato 
the internal jtit;idar \-ein. 
Intralabyrinthine Suppuration.— See p. 259. 



Abnormal Conditions occurring as Sequelae to Chronic 
Suppuration in the Middle Ear. 

In the meatus, lusuhs those cnnditions already described, 
vaueus contiaet ions may be found. These may take the 
form eith.-r ol a diap'iiaeni entirely (}ccludinf.^ tlie meatus, 
or (it a cicatiiei.d ( (inMaction with a central pi rforatioii. In 
the biruH r instance supjiuration will lia\-e ci ased ; conse- 
i|uentlv behind ibis \\eb it is rare to lind retained secretion, 
lb hiiwi \ei. there is a hole in the centre of the web. UKire 
heipieiitK' tlian not sU|i|iuration is still ;;oiiif; on. and ]>us 
Is ( .xuded nmre or less copiously thr(iu/.;h the opeiiiiii;. If 
die u(b be (dinplete and deafiiess result, a ( rucial incision 
■liduld bi Ml, id. ihe knile (littiii^ ii-;ht dnwii lo the bone. 

or ,1 I in lll.ir im IsKHI made lo lelildXe the wlmle nf I he dlistrue- 

'icn, .\ iiiei.il iiibi' sbduld be .itterwards iiitrddiici'd nilo the 
meatus l,ti!.:e ( ndu^h id lit Kuiiv tit;ht!v; this dil.itor must 
be retaiiud 111 the e.ir Uir .ibnut ,1 nidiith or si\ uicks,. the 
passage irrigated iwe oi ihiee times a diy with ,mlise|,|„- 






178 



ii.i\r>i:(i(ih' ni- i>i>r,iSFS oi- mr r.iR 



Inlidii. and llic tulif taken (nit at Inst owv a day an<l cleansed 
and rcplaci d. '1 lie wound li(al> in the (■<>ui-~c <il a week <ir ten 
(kiys. 1)ut it i^ nrci --siirv to kt< p the tidic in tla meatus lor tlie 
tiiiK' nieiitioni d in oidei' to ox-eicoini' the tendency of a second 
nienduanons well to form tlirouj^li cicatricial contraction. If. 
lio\\e\-er. tliere is si ill dixliar^'- sliowin;,' the ]>iesence ot 
suiiimr.ii ion in tli^ iiiddle e;ir. it i^ wiser immediately to per- 
form a radit al ojuration than to attt nipt to dilati the stricture, 
as this is a ii ilious iirocess. and not iht oretically. at all 
f\( iits- d, \did of risk. Dm uii,' the process ol dilatation, 
il laniiiiaria leuts are used, as is mmmoulv adxix d. th( pits 



6.F 




ric. 5^- -I'Ki r\K A HON siidWiNo iiM HANDi.r; OF iin Nr\rLr:i:s 
liof.M) DOWN I :\' I K \iKHi\r iissii Al 1 r,K < I ss.\ rioN or 1 in;iiMr 

SUri'lKAlION. 

.S7'. Sliort jirocfss ; M, cicatricial membrane: /', tip el ni.illi nl.ir 
luimllc a'lhiicnt te iirdiiiiuitciry. 



is rei liui d as loni; as the tent is in I'o.sition. and "-ejitic ahsorp- 
tion is . neuura,L;ed. I'nli -s the dis, ,|s, in tlie middl ' i ar i-^ 
cntinh' emtd e^iiti ,m l inn will oi(ur attain, and th<' ]iatient 
wi.iiiii a short I iiiie willln 111 the same >late as it no Ik at iiieiit 
had 1m ell adojiii d 

lli( memhran.t tvmpani itself may exhihit manv p<>st- 
suppuialixe ( h.uigis. It the oiii^iiial pei fora! ion u i re ex- 
tensive ami have become eiitiiely lilh d in this -ear niein- 
hrane will |i. thinner than the normal will loiit.un lar l ss 
fibrous ti.ssue. and at the sanu" time thi^ !il irons iissui- will 
not have the nccossarv resilieiicc nor ]iropi i .in aii-ement 
i»f its fibi-i'S ; it will thus lie « ,'.sily iiitliaiKed !■> ili.in;;is m 



MiDDT.r.-FAn ciinoxic svpituativf i)fsr:,isr:s i;.) 

pressure either from without or within, and in conse<iuence 
it often lieconies t'xtrenitly retracted, even to the extent of 
lyin^' closely ajipUed to tlic inner wall of the tympanum. 

In the reverse condition of this, afttr -uj^puration lui;' 
ceased, a large ]iart of the miinl)rane is found to liave under- 
gone calcari'ous degeneration ; this is not to he attributed 
always to thr cttVet of sujipuralion. l)ut partly to coinci- 
dciK-e. as this chalky change is fomid witli ('(jual fri'tjucncy 
in patients, sonu' wvy yotnig. wlio have never suffered from 
su]>puration. 

\i other time> tlie memhrane does not e\liil)it signs of 
h( aiing. and the perforation i)er>ists. tlie edges of wliieh aie 
usually thickened and roun(h'd. having much the a])]H'arance 
in miniature of the edges of a chronic ulcer of tlie leg. This 
variety ha^ heen termed a residual perforation, and it is 
I)ossil)le at times to ol)lain its liealing hv means of the irritation 
of its I'dges. This mode of treatment is only advisable if 
the ])erforaf ion In- small, and if a jiledget of wool making good 
the gaj) imiirove tlie hearing. The sHght oiuTation should be 
done under mild, tliongli caieftil. antiseptic precautions. If 
the antiseptics used are too strong. th(> moderate degree of 
mtlammation which is n(M-essary for the healing ]iroc(ss will 
be checked. 'l'!i. re are two agents wliieh iiaw been found 
u^elul in such cases, naim ly. cin'omic and Irichloracelic acids. 
it the former be cluNeii. it nnist lie used on the ti]) of a line 
]n-obe ; a few crystals of the acid are pledged up by the pndie. 
wliicii is then heated in a spirit tlanie ,in inch from its ti]). 
The crystals melt, and the i nd i-> uniformlv coated with tin- 
acid by the simple plan of rotating the j.robe. .After the 
c.mal has lieen syringid with boracic lotion and diied. the 
]ire|)ared probe i> careinllv .ipphed to the eilge of the perlor.i- 
tion. ('.union niiist be exeii ised to a\<iid the a( id running 
and so e,uiieri/,ing otiiir parts. With trii hloiacet ic acid it 
is bettei to t.ike the deliijuest'ed ii id cm a small cottonwool 
mop an<l ^I'l'lv i' in the same way. A little iddufdrm m,iv 
iiiin I i( i!i.-.ii t'l.i i V i 1 . and llh nii atus lii^htls pa( keil willi an 
aiitis( |itic wiMil (ir gau/e. At the end of a day or two the' 
t dge of tlu perforation sliould bi' pink, aii.l beyin to show 



-I 



it' 



iSo II.IXDBOOK OF DISEASFS OF TIIF FAR 

a tind.nry to rl(»sc : it is. howcviT. Kfi^'i'^iHy necessary in 
stimulate the iilges in. in time to time. 

In other instances the edKe oi the luifoiation in the 
m.inhra has Iweome adlien nt to thr inner wall oi the 
lyninanuni. whilst in others tlie ossicles are botiml down to 
adjacent striutiiits by means of cicatricial hands. 

The treatment of these cases dejM-nds on the amount of 
,1, afn(s> e.Njxricnc.d and on the amount of imiiiovem.nl 
,1, rived from aititicial memhranes. If the d, afn.'s> is trouhle- 
some and no materuil relief is ohtaiuMi l.y the use of the so- 
called artilicial dnim. then minor opeLitions should l.e tried. 

Of these operations there is one which is a fairly reco,i;ni/.e'.l 



il 




lU;. ;4.— C.\KK1I K lOK INTKOnrClNC. 

mi-;mhh.\nis. 



, lAI. \\ MIANIC 



D, 1 



ul)lHr <lisc ; .S', Ihr-a.! atta. lir<l t.i 'li-c 



procedure- viz.. the so-call.'d circnmcisioii of the .tapes; 
it may he tried in .ases where the stapes is Inmlv tied down 
into the niche of the f.^iieMra ovahs hv means of eicatruial 



tissue 



\{uv cocaine or eu.aine. or (ir;iy's solution, has heeii 
ap'pli.'.l and. the part rendered insensitive, a spn<hsh;,ped 
knife or a sharp i-ninted mvrm^otome is used to divide the 
scar tissue hv l>aiallel hues ,h,wn almost to the holKun ol 
the feiiesli.i ovahs. Mateiial impioveiiK'ut <.f h.'ariui; will 
fn.iuentlv h.llow. hut the veMilt do.s not uaiallv last for 

,„„,,, ,l,;i„ a lew weeks. wlhU the iL atlUeUt lUUst he repeate.h 

the surgeoa endeavouring to h.llow in the hu.s ot the on^m.d 
incisions, and m a fair proportion of case^ a lUgui -I lasting 
impioveiiunt is ohtaiiied 



MIDDLIi-liAh CHh'OMC .^77'/'/ AM 77 17; DISr.ASF.S i8i 

A iiiodilication of this line of trfatmcnt consists in applying 
a minute quantity of chromic acitl into the fresh incisions, 
so as to cause a slou,i,'hing of the cicatricial tissue, and thus 
jirevent the necessity of mo'^c than oni' operation. Tliis 
method has a slight disadvantage, inasmuch as the Falloinan 
canal is sometimes deficient in tins region, and the swelHng 
set u]) may cause tem])orary facial paralysis. Otiier di\-isions 
of ciciitricial tissue mu^t necessarily depend uj^on the situation 
of the l)an(ls. and at tunes it 's justiliable to jierform a com- 
jilete ossicidectomy with the liojie of inipro\'ing the condition 
ol deafness. 

W'iien the perforation is in the upjier ])art ot the memlirane, 
and tlu' edge of the meatus somewhat destroyed by the sup- 
]iurati\'e process. fS|ieciaIlv if the attic is in\dl\ed. a condition 
almost a)iproaching cholesteatomatous formation is ol)Seryed 
■ — that is to say. adherent flakes of skin are found which have 
formed in this situation, and are not thrown off. They can 
lie easily remo\-ed liy tlie ,iid of fine torce]is alter ha\ing been 
loosened liy the u>e of a ])robe ; their ri'mo\ al will lre(]uently 
very consi(Ural)ly im])rove the comfort of the patient, and 
alr.o perhaps his hearing-jiower. 



1 



ill* 



CIIAPTI.R XI 
INTRACRANIAL COMPLICATIONS 

Pathways of Infection in Otitic Intracranial Disease. 

iNrKCiKiN may !»■ tdiiwvol tn.ni -rptir ((iiKlitidiis in the 
nii.l.ll'' nr intrrn.il .ar aiui a.ljac mi parts ..f tlu- mast. .id buiic 
t,) tl',' iiuiiiiii^vs. (crcbnim aii<l .vr.li.'llum hy tlic fdlnwiiig 
nuitrs : l-rnm the mi.1.11. .ar tlir..u,L;li an .niH.in of tlu' l".iiy 
cnv.riiii; or a natmal .l.'liiM .n. .■ <i! tli.' bciiy .dvcrinK of the 
rar.iiid .anal tin r.Lv .■iiaMm.u pn^ 1" inid i'> ^vay aLm^-id.' 
of tlu' art.iy; tln-.m;;li .i.'-i-n ..r .ilisnii'.' .if llif tc^'m.'U 
tyiniKUii : liv thf i.as-af;.' ..f i.ti> tlnoiiKli ^ui .Hcasioiial -.-.i.-. 
of (-.■lis nmniii- t!ii<ni,i^li tli.' lu'lnnis luution of tlu' t.'mpoial 
l„,n.'. oiHuiiiK on til.- oi>" l.an.l into tli.- .avnm tympani 
;Uiov.' til. ..n!;;-. ..1 tli.' iuist acliian tnl..'. an.l .iii tli.' otluT int.) 
tl„- mi.ldl.' fo.->a ..t til.' >ktdl- flo>.' t.. th.' Ca^s.-rian ^an^Iioii ; 
v.i-y raivly in.l.'..l l>y tlic facial .anal ; Ivom the antnini. by 
iMtli.T .an.- or n.rrosis of its \vall> ; ffoin ili" lal.\nnth. 
thnni,i;li tlu- int.M-nal andit..iy in. atn-.. ihi.ni.uli p.'vfoiati.in 
,,t th. Miii.rioi s.ini.ii.-nlar .anal. ,in.l I'V th.' a<in,e<ln.tn> 
v.-tihnli. •ill-.' mav I..' lak.n t.. ivpivs.nt tli.' | m.ipal 
(i.uts by win. li inl.'.tion is carri.'.l within th.' .'i-inal vanlt. 
an.l wliiVh a. t as th.' path\v.iy-> hy whi. h inf.'.tion in m.'iiin- 
j^itis, .'xtia.hnal al.>.v>>. ciamal an.l . .'i-.'lullar al.Ma>^ is 

(•(in\'.'\'t'il. 

Meningitis. Infi.ti.'n .il th.- in.'ninK''> "' ''"' '""•^'" '"'^V 
ocfin m 111.- ..aiis.' .if ..titi> in. .lia, Mippnraliva. cilli.-r m 
anit.' ..I— v.nh p.Tl.uati..n ol th.' lyinpam.- im ininan,- ; 
as a srijni'l to a. tit.' ina>t..iditi-,. withont j.. li.n ati.ui ol tlic 
diiim ; Ol- in . hr.'iii. -nppnral p m of th.- ini.l.U.- . ai , 

I >j 



]\I. nin- 



IXlh'ACh'. i XIA r. COM PLICA TIOXS 



i«3 



,L;ilis in;'.\ coexist with any of the other septic intracranial 
coniphcations. 

SvMl>T(iMS.--Tht' patients complains of fcverislmess and 
ccphahilgia, ushered in at times l)y a slight rigor, with vomit- 
ing, and he has at this time a cinick and lull pulse. With 
the progress of thr disease the cephalalgia becomes more 
uitense. aiul. in common w.'th th(> olliei' otitic- ii racranial 
cnmplications. becomes so si wre that the patient cries out 



\\H 



h pain. Intolerance of light, at times ainoimting to photo- 



1 , 



;)ia, wun nyper;esthesia acustica, together with marked 
retr.iction of the head in basic infection, become marked. 
Tlie pupils, which are commonly mieiiual. reaci to light, but 
u-.u.dlv more or K'>> slowly than mtrmal. Optic neuritis. 



nr 



apillitis. 



i'' 



wi ; m mo^ 



St cases be noted. The jiatient now 



tends gradually towanU a li-thargic state of mind and body. 
Il'c ]mpil> become widely, though often uiKMiually. dilated. 
,uid all reaction to light giadually i> lo^l ; whilst in basic cases 
a teO'leiu y to >(iuinling is more Irecpiently noted than :n 
other \arieties. A jartia'. paralysis, or hemiplegic condition, 
mav set in at thi> stage of the disease, but e\-entually total 
I>aralysi>. with ^tertor uid profound insensibility, will occur 
if the effusion is great. '1 he pul>e-iate during the latter part 
(it the illness is ra])id and irregular ; the respirations are also 
niegular. though slow. Nystagmus may be present in the 
later stages of the disease. 

rKi:.MMi:NT. When the p.itient is seen at the conimeiice- 
nient of the affntion immediate oper.ition offers the liest 
Ihrp,' (if savmg lite. The meninges are freely exiiosed. either 
\>\ an e.\tension of the radical niastnid ui.eration or by the 
lemowil "I a large piece "f the o.iiietal bdiie and incised, tiie 
inimediate area ot disease bathed widi boracic lotion .md 
dressed with antiseptics. A culture from the infected area 
sliould be taken, and a vac.cin.' in.ide ,ind injected, or if this 
pio\, s the preseiut' of str>'p.1ococci, the effect ol the anti- 
loNiii may b.- tried. Lumbar puncture as a means of diagnosis 
is ol extreme vahu> lb>r the diiirienti.d diagnosis, see p. 195). 
Til, most hope from drugs (onit s trom a careful .uid judicious 
use of mercury and Inuk. combiiuHl with opium lor tlu relief 



i iM 

f 1 



i 1 3] 
i: i >1 
1 A I 






II 



If! '! 
ii ! 



\h 






184 



//.;.\7)/;r)o/\- oi- disi:asi:s of thi- i:ar 



of pain, or large doses of calomel and ciuinine ; ice-l)ags to the 
head slionld lie eniiiloycd. and the ]iatient kept strictly quiet 
in a darki n((l room. Lumlnir puncture is alx) recommended 
as a means of treatnirnt. 

The depression mid dr:!in:igi. ni)eration of Ilaynes deserves 
^(>n^:d^•lation. 'i'lie patient lies fare downward-;, ;aid alter 
the necessary i>reparations an incisi^^n is made dnwnw.trds in 
the middine tmm the occij)ital iirntubeninee to the spimuis 
l)rocess nl the a.\i>. After e-Xjiosing the skull, a disc nt Imne 
is removed about i inch a])o\-e the foramen magnum. '1 his 
ojiening is enlarged downwards, sn as to cnnnect tiie trephine 
opening and the luramen magnum. Thi' next ^tej) is td incise 
the dura vertically in the mid-line, behaving according as the 
]>resence or absence of an occipital sinus demands. The sub- 
arachnoid space is entered either b\- the original cut thiough 
the dura or bv extending the dural incision. Too nipid 
evacuation ot the subarachnoid fluid niU'-t be checked, the 
state ot the l)lood-pressmv being the most reliaiile guide. U 
tlu're is reason to susped iilugging oi the ior.inui! o| .Magcp.die, 
the i)ostenor I'oles of the cerebellum are gently iiushed up and 
apart. Dr.iinagi' is obtained bv means ol a -heet ol thin 
rubber lolded up, and about \ inch wide. 

Extradural Abscess. — For routes of infection, see a)itc. 
Tlie abscess is eithi r situated external to the dura of the 
middle fossa, or. when the infection ])roceeds throu.gh the 
antrum and the jio^terior < dls roiuiected with it. in the 
sigmoid groo\-e between the hone and the lateral sinus. '1 he 
extradural collection of ])us found in the middle los>a is almost 
invariably the jirodtict of (duonic su])]iuration ; whereas the 
abscess situated in tlie sigmoid >inus may be iound a> a result 
eitlur of ai ute or chronic supjimation. 

>VMiT(iM>. The onl\- constant symptom in extradural 
ab'-eess is ( ciihakd.i^ia. This is often so intent' that the 
jiatient rolls m agony or cries out with pain, and is unable 
to sleej. at ni,L;ht. Tliis severity of suffering is more esjiecially 
the ease when the abscess is the result of chroni ■ sui)]iuration 
(if the mitldle e,ii-. l'( rcussion over the s(n,ainous portion 
ol the temporal bone or deep pressure will Usually locate a 



I- ^li 



/ .V Th\l C h\l XI. I L COM PLICA TI( ).V.S 



iS; 



small ]Kiinf!il an-a, at which point the pain is most noticeable, 
and from wliich it r:uliait^. The ].ain is of a neural{,'ic 
cuaraeter. sjireading upwards o\-er tlie >ide ot tlie head. '1 lie 
temperature in acute cases is high. l)ut m chronic o*''en slightly 
raiseil alio\e the normal. The jiulse may he either unnaturally 
slow, normal, or slightly accelerated, and. if the extradural 
aliscess is uncomi)licated. it is rare to fmd oi)tic pajiillitis. 
Thus reliance has largely to l)e ;lacrd upon the history ol the 
case, wliich may he that of an old-standing supjnn-ation from 
tlie ear. with gradually increasing ce])lialalgia ; at the com- 
meiicemeiit the pain is little more than a severe headache, 
hut. as noted Ixfoiv. it may lu'come sufticiently severe to 
pre\-eiit sk-ep and cause the greatest distress to the patient. 
If the abscess lu'comes (/f large size, there may be symjitoms 
of cortical irritation, as evinced liy spasms of the muscles of 
tlu' limbs on the op])Or>ite side of the body- and in rare cases 
the patimt may become comatose. The acute cases are 
those following influenza, and will occur when the mastoid 
consists entirely of cells. In such cases the ])ain will ha\-e 
been severe, and the whole mastoid ])rocess teiid.er on jiressure. 
If this condition is not recognized and suitably treated, by 
o])eration. eitluM- lateral sinus pyaemia or ■^ep.tlc meningitis 
will ensue. 

Tki:.vimp;nt.— Operation alone affords relief to tlu' patient. 
In this, the mildest of all the intracranial comj'lications ilue 
to suppuration in the middle ear. treatment varies with the 
acuteiiess 0-. chroiiititv of the atta(d<. In acute cases the 
mastoid antrum should be lust opened ; it is always ad\isable 
to \\<irk from the antrum towards the abscess, iollowing up 
the tra( k b\' which the iniection jiroceecU'd. In clironic 
cases an examinalioii siiould be niadr in every instance both 
of the middle fossa and the sigmoid groove'. Should the dura 
iiiati r or the lateral sinus appear unhealthy when expos'/d. 
further examiiiat ion of these parts should be ma<b- a.^ described 
under the separate diseases. Having evacuated the abscess, 
the cavity >\\o\,. ' 'ne idealised with a strong antiseptic solution. 
su( h as Lister's stroiie, lluid. and the wound. ha\-ing been well 
liustC'i witii -axioinrin, is iigin iy piuggeii iu.'in iiie ijdii.uu in 



,!i 



HAXDIIOOK OF DISI^ASr.S Of THE l-.IR 



chronic cases where tlie radical mastoid ()])erati()n lias iieen 
jierfornied. the end ot the phig may he drawn thron.^h th" 
external meatus ; hnt e\-en in these cases it is hetter not 
to close the woimd I'ntirely. In acnte cases, where the 
radical operation has not heen performed, the womid is not 
I'lUirely closed, and the end of the .Ljanze strij) is hroti.^ht out 
into the lower ])art. Tin- e\aciuition of the pus is tojlowed 
1)\- an incision of the tympanic nieml)rane. tor thi< measine 
is usually necessary. The whol(> of the i anal i> ik.w cart iullv 
irrigatt'd. and the I'xternal meatus plugged from the hottom. 

Otit.'C Cerebral Abscess. — Cerehral ahsce>s occur> in the 
majority ol instances as a scfjuid to. or conii)lication of. clironic 
purulent otitis media. Acute sup]iurati\-e otitis media is 
occasionally tlu' sotnx'e of iniV'ctioii. Cerehrcd .ihscess has heen 
known t(> follow an attack of acute otitis media in which no 
perforation of the tympanic nu'nihrane has heen ohseixtd, 
Init in which ahscess or inflammation of the ma-toid .uitnim 
or one of its cells has occ^u'ied. (For modes of infection, sec 
aiile.) 

The lollowing description of a cerehral a!>scess situated in 
the teinporo-sphenoidal lohe may l)e considcri'd as ty]iical, 
l)ut it iiuist l)e home in mind that one. or evt'ii most, of the 
more characteristic signs may he — indeed, (ifteii are — alisent. 
Also, when the ]iati(>nt is tirst sten. either in the late secondarv 
or third stage, it is chiefly hy a process of deduction and of 
exclusion that it is possiide to arrive at a correct diagno>is. 

Abscess of the brain may !)e divided (linically into three 
stages. In tile tir>t stage the patient is. in tli" majoriis- of 
instances, a sufferer Irom chronic otitis media : he lieconies 
suddenly ill. and a history of a r^'cent chill or in|iiiy to the 
head may not iiifre(iuently be obtained. In ihi>. thr earhest 
stagi'. the .symptoms are tdiielly releri-((l to tlie cir. Pain 
is tl'.e |iiomiiieiil >ym]itoiii. and is of a hot. burning, or slnHitiiig 
charact( r. ^pr^'.lding. after a short iiiter\-al, o\ei- llie tenipoial 
region, uiiere It often l)ecomes cliietlv lo( ati'd. and tin n apt 
to liecome most \ioleiit ill character, inch causing the most 
intense' agony. It may be either ji.rsisteiil or intirmilteiit, 
Inil oltiu s(i se\iii,' that tile [i.itieiit is .dniost unable to luar 



IX TR. 1 CR. IXIAL t.( )Ml'l.lC.l 7 lOXS 



ra; 



it. Vomiting, not refcralile to the ingestion of food, is likt'ly 
to occur at this stage, and eitlier Iwforc (.r at tlie same time 
as the onset of vomiting a -hglit rigor is usually noticed, with 
a moderate rise of tcm])eraturc. This probably dues not 
exceetl 103° F.. and in uncomplicated casi'S the rigor is ranly 
rejieated. The general state of the tem])erature dm-ing the lirst 
stage is only slightly above normal, whilst the pidse is (]ui( 1> 
ened and the tongue becomes furred. The jiati-nt is oli\-ious1y 
very ill. and at the unu' that tin- rigor occurs the discharge 
from the ear. in the great luajority of instances, is lessened 
in (luantity or ceases entirely. 'Ihis ^tage is of \-ariable 
duration, and may exist for a few hours or several da^'S. 
It is. howt'ver. randy that the patient is brought under oli- 
ser\-ation at this tunc, as not infrequi'nth- he ha> suffered 
and recoveretl previously Irom a (imdilion \'ery similar, 
though of a k'ss severe type, whii h was probably due to septic 
jxiisoniug ironi absorption of the i)roduct> of >uppm-a,tion. 

Ihe second stage is tli.at in which the jiatient is commonly 
seen. By this time the pain has become considerably miti- 
gated, and the state of the patient tends more towards a dull 
and (juiet state of mind and bofly. so that he is apt to lie 
(juietly do/ing. exceju during attacks of i)ain. Pain at this 
tune is not loudly lomplained of. but niav be elicited by 
percu>sion over the ttinporal bone, and the head may l)e t(-nder 
on i)rcssure o\-er the same area. Cerebration is delaj-ed, and 
though at the beginning of the second stage (luestions will bo 
answered correctly, but after a di^tiiK t interval, wi. as the 
aliscess increases in size or as the >ymptoins become intensi- 
hed. a distinct loss of memory will often be observed, this loss 
being lii'st niitii-ed in tiie in.d)ihty on the ]iart of the patient 
to remember the names ol ]ila<-es with which he is ]ierfectly 
lamiliar. He will be unable to slate where lie lives (cr to give 
the correct names of common articles, and there is little 
evidence ol spuiitaueous icrebration. The inclination to 
sleep beconu\s greater and ,it the same time the slee]i is 
troubled, restless, and biokeii. The tempi'rature \-aries in 
this stage from (,7° to i,(," F,, being more fre(|iieiitlv slightly 
l>elow than al)ove normal. The pulse-rate sinks gradually 



m 



m 






T-t 






iSS 



If.lXtUlOOh' OF DlSI'.ISrS ().'■ THE i:..h' 



m ' 



f . 



*i! 



til ;i r.itc Narving from ,;<) tn Go jut miimtc. and toj^ethrr 
witli till' >mking of t!ic pulsc-ralo a diminution in the r.nnibrr 
of riNiiirations prr mimitc will he notrd. tlicse not infrequently 
lalliuL; a> low as ii or 12. tliou,L;li in ccreijral alis^TSS this 
slowuos of re>j)iration does not ecjual that oIisti\ed in eases 
of ecrtlxllar abscess. The bowels are usually obstinately 
I'onNliiialcd. and tlicrc is a lo>s of control o\'cr the bladder. 
\\lii(h is e\-inri'il ritlni' b\' retcnlion or ir.cdiitinenic of urine, 
and albumin is usually present ui small (juantuies. \'oniitinq 
and iiiddiness are jircsent wlu'U the jiatient is able to move 
about. Paralysis, whm it occtns. aids nuiterially in localiziu},' 
the site of the ab>cess. Thus jiaialysis. when obserx'rd on the 
side of tl'.r body oii])osite to the seal of the lesion, nuiy !'e 
I'itlur ol the cortical or inti'rnal ca])sular variety. In the 
former instance the ]i;;ral\'sis occurs in the following order : 
rirst. the fai ial nuisides. then those of the arm. and. lastly. 
tho^e ol the leg ; but the lattc r are only slighth' affected atid 
si'usalion is ])reser\-ed ; while in j-.u'alysis due to pressure on 
the internal cajisule the order is inverted. ]>eiiio 1,.^. ;irm. then 
face, togetlur with loss of sensation. When the lacial nerve 
is ])arah-/,eil from tlu' jiresencc of an abscess of the brrni. the 
loss of power is not so complete as that which occu 'U 

a le-ion to the ner\'e in the Falloi)ian canal. The stale ui 
the pn]>il on the affected side \-aries. It is frecjuently con- 
Iractt'd. and onlv reacts sluggishly to light and accommoda- 
tion, in wb.icli case the ibscc^s will be relatively small. But 
if the abscess is of lai"i;e Nize. the pujiil on the same sid<' w '!l 
be both dilattd and st.able. T'araKsis (if the third ner\-e on 
the same siile as the abscess is a \ariable sign ; that of the 
si.xth is less common. ()ptic neuritis, or jiapillitis. is found 
dming the whole of this stage, and ma\' be only on the affected 
sidi'. The tongue becomes furred, and towards the end of the 
second stage sordes are freijuentlv jiresent on the li])s and 
teeth, while a strong ] ml rid odour emanates h'oiii the i)atient's 
breath, and where consciousness is preser\'ed a subjectixH' 
bad odoui" may \)v complained of. 

The iiossilile terminations of cerebral abs(~ess after the end 
(if the second slage are cither spontaneous evacuation, or. 



IXTinCh'.lXf U. COMI'l.ICJTK^XS 



189 



when the disease is untrtiitcd. tlic pal lent ])asscs intci tlie 
tliinl and final stage Spontaneous (.■vacuation occasionally 
occurs liy discliargr of tlu' alisc( ^s through the txtcrnal meatus, 
the pus ]ia\ing lound its way tiu-ough tlie cerebral li>sues. and 
through a l-sion in Imili the dura mater and tegmen tympani. 
This is a rare rtsull. but one wliich has been reported from 
tri '(' lo time. 

In the llnrd stage iiroi)er the ]«alient lies in a dee]-) comatose 
condition, m which ( lieyne->toke> rispirati<in is common. 
This condition after the lap' e o! a short pcii(jd terminau^ in 
(hath. 

Tki-.\tmi-nt.— Till' .reatmeut in the hrst stage will consist 
in a )re]imiiuu'y radical operation on the ma-toid. with an 
exploration of the liase of the middle 1o>sa. liy cutting away 
the tt'gmeii tymiiani. As at thi-. stage there is no formation 
of pus in tlu' brain, no indication may be found to proceed 
furtiier. Such an indication would lie a uon-jiulsatory bulging 
of the dura mater. 

In tlie Second stage, although a radical mastoid operation 
must he ])erformed in order to remove the jirimary focus of 
disease, the condition of the patient must guide the snrgi'on 
as to tlu- desiral)ility of performing this ojieralion at thi' time 
at which the abscess is e\acuated. Should the radical opera- 
tion have been performed, the bone may be removed until 
'he same region has been exposed as would have been ex- 
poseil by tlie trepliine l)eing a])plied over a sjiot ij inches 
bJniid ;'nd i| inches abo\-e theceiitre of the extt'rnal meatus. 
(.Ill exposure, uie dura mater is incited and the brain explored 
either by means of the blade of a bistoury, llorsley's cereliral 
jms-searcher. or a large trocar and cannula. Should this 
mea-ure fail in locating the abscess, the sterilized finger is. 
after incision of the I'rain substance, introduced gently into 
tlu' Cerebral ti^-^ue. and tlie aliscess mav be detected by a 
sensation of resistance and then evacuated. Alter [nis has 
been found, the instrument shoulil on no account be with- 
drawn unless a din-ctor is Ic^ft with its ]ioint well within the 
altscess cavity. A double drainage-tube, as large a <r/x as 
possible, should lie passed into the abscess cavit\-, which is 



10 
I Iff* 



!■' f 



igc HAxnnnoK or diseases of the j- i^; 

thon irripatcd witli lioracic so];..1i(;n. Tlu'Sc tultes should 1)0 
Secured l>v Milures and ihe vvound dressed. After the evaeua- 
""" "• I'i'>- ilic pulse will lieconie accelerated, respiration 
will ;igain heeoine normal, whilst the teniperalure will rise, 
to t;ill. if the ease p-ogresses favourably, witlnn a few hours. 
.\s s.Miii as the ]>ns has ceased discharging from the abscess 
walls the tub, ^ sliduld be shortened and eventually removed, 
and the -ealp w«Mind closed by h-esluning and sutm-ing its 
edg.'s. 

Intradural Abscess is .dnmst e\e]usi\-ely fomid in the 
]'iisi<ii(ir fossa, and is sitn.iied in cldsr jiixta]insii i,iii lo 
tlie jiosterior surfa(-e of the jietrnus l.diie. its urigin being 
direct infe(-ti(in from a s, piic lahyrintbiiie lesiun. nr direct 
infect inn thinu-h th.- m.i.ti.id cells lying ]i(isteri(ir and slii^litly 
internal to the anti-.im, The s\-ui]it(ims are \agtie. chiefly 
those of compression of the brain. Localizing symptoms 
are absent, but lo(-al j.ain is comiiK n. ']'he teinjieiatnie Ls 
rarely much ebwitxl. .\ blood-icmit will probably point to 

the presence (it pus. 'llie I atient's (dlKbtinU \aiies Irom 

sh-ht ce]ihalalgia only to ceplialal-i.i with marked ten<lerness 
ol the region to iierciissi(.n. it is to be it iiiemberdl th.at 
these abscesses are olli n associatid with ( .rebellar absce',;s. 

Tki- ATMKNT. — .\tter a radical mastoid operation has been 
perlornied. and the labyrinthiiK^ snpp,i--,i,, l,,iik.d ior. the 
posterior wall ot t be opti-at ion ( a\-it • rried bach int( ; nallv 
to the sinus iludjieiiing b( iiiL; made as la it;' as pdssibl-. 'Jhe 
pus can be evacuated ihtou-h this (ipeiiiun, .\||,.r n^ cuni- 
plete n Tuoval tli<> ra\-i;y is tc be thoroughly ( leansed tilh'd 
with io(liiloini I inulsioii, and pai ked with g,ui/e. tlie test ol 
tli( opi I, it ion (.i\-iiy beiiej tnated as bef( ce laid down. The 
wound must be only part .ally closed in jiennii of stdisiijut iil 
dres>;,in,i:s. 

Cerebelhir Ab<;oess is rarel\' aiutc, i.nt nia\- mn an .nlinly 
l.itiiit co'-tse , .d on account ol the ililtn idly ol dist ini^uish- 
ing intradural abscesses fnuu true cert bellar in the r. pmis ot 
cases, exact iaiuilation of symptoms is diniculi, 

In cerebellar abscess nyst.ignius is alwavs present, and 
hill in lies niie ol ihi piinMp.il iba:;noslii ijiltn idt ies. |n 



if 



/ .V TRA C R. IXIAL COMPLICATIO .VS 



191 



\ ! 



Jaliyrinfliint' disease the nystagnms. when elicited, is. if 
llie laliyrinlli is .cencially inleeted. towards tlie sound side ; 
wlieii till- dr^tviutioii lit the or.qaii is comjilete. alter a lniel 
interwal of iii(rea--ed iiileii^ilv. it ceases. Cireliellar iiy^tag- 
]im> inav he to either >hh-. 11'. however. nv>tagimis towards 
tile disra-M (1 >idr the ii\Nta,e;imi;; is jirehably cerebellar ; it 
towards the snuiid side, it is either eireliellar or a locdi/jd 
lahvriiithir.e iitiretion. W'itji a iioii irritahli' hdtyi'inth tlie 
])resi'iiee n\ n\'stai:nni> ]>oints to cerebellar abs( i>s ; Init when 
the iivsta,:.;mtis is tnwiirch the Mnnid side, with a non-irritable 
l.di\iinih. no iert,iint\- exist-;, and it has lui-n advised that 
till- Idivrintli bi ablatrd and tli<' 1 [fi ( t noted., but tliis seems 
a most (]ui st ion.diie ]ii(icedure. Careftd obserx'ation of tin.' 
]>;'tiint is better, and a blood-court may assist in eleariiif; ui) 
till' diat^iiosis. 

'llir temperature is not usuallv raised, cerebration is 
slow, and a drsjre ieir sleeji cil'tt'ii present. p.radycardia is 
tie!]iniit. and thr )'ube-iate I- not olt<'n it! ketjiuii; with the 
temiMialuii . ("t I'lialali^ia. 1 Men localized, is a 'dinmon 
symptoni. lhnui.;li it mav be hon.tal. Stiffness .md jiain on 
]>resstni' on the ninsi Irs ,it the b.iciv ol the neck is alsn a 
valnablr sjnn. N'miiilin^ imassdeiatiil with tic in,L;tstion 
of tood. optK ]%ipillitis and choked discs, an- both ; ommiiii, 
the tiist espe( iall\- s(i. S(|uint issometinirs iound. 

Ciivliellar ataxv is most mark'd when thr j.atieiit walks 
with rioxd eyes. Jumiuiij; aad boppint;. altlioHuh able to 
show this brit< r. slidiild not bi put in jiiai tiii'. as tin jarrin,!,' 
may br \ii\- di li triioti-. liii- p(i~ition ol tin- In, id altrcts 
the Rait . \\ I .d^n. S-, nl tin hand-,L;i ip on the alie< tid side, and 

(li l!i( Ir- im the s;im'- sidr. tof^etlier with ill' leasrd kill r-jel k. 

ni,i\- !»■ louiiil. 'I'lic .lUilude of the ]iatient in bid is i haiac- 
tiii^lie ol till I Itii I ol '.ell bral iriitatioir liiat is to say. he 
tiiids to III 1 oili d up with 1iim1\' .md limbs llexid. and looking 
away fron^ the affected side. 

Tki \iMi\r rill' masldid should br examined either at 
tlie saiiw time a> the ab .ess 1, scuif^ht tor or later. With 
the spi I lal object of explorinj^; the ceiebt Hum. a iiiued 
ini isimi. with till coii\ixit\- ui'waids and e.uiimeni iiij; 1 lose 



'■\\ 



.ij.i 



mi 



192 



i[.i\nn<n)h- ()!■• Disr'.isi:s oi- riir: r.AR 



IN 



heliind ilu- piiin.i. i> carried liackwanls ami downwards to 
alidut I ', 111 2 iiii lit s lichiiid tlif mastoid ]irocoss rii,dit down 
to till' lionr : the (HTi]iital artery is )i>ually dix'idrii and all 
llie ti^suiN. in( ludinu muiic of the ^telllo -mastoid nnisde, 
rellec ii d --o that a trephine can he aj pli( d to ih" ^knll in >neh 
a way that it lies at^'ain^t the posterior hnrder ol the mastoid 
proii'-'N. with it> nppi r edi;e In-low Keid'> ha^e line. Alter 
till' di>e ol luini' has heen removed and the dnia mati r opened. 
the instrnnunt nsed as a iiu>-st'ar(-her shotild he pu>heil 
firstly lorward■^. np\vard>. and inwards toward> the >nrtacc 
')[ th( petrons hdiie. It jHis is not fouii'I in this direetion. 
and a> it may lie more than i inehe> Irom the Mirlace. tlie 
fmi^'er should he introdne. d and the eerel.ellnm t \plored. 
espt'cially touanK the ttiitorinin. where the .ihseos maybe 
>ilnated 1)( tweeii till' npp( r Mirtaee of the eerehellum and 'hi> 
structure. When th.' absci'ss is lonnd and evacuated, the 
same line of conduct must be observed as was recommended 
in dealini; with cerebral abscess ; but it is w( 11 to remember 
that a Second cerebellar abscess is occasionally present. >o 
that, if the symptoms are not reliexcd after evacuation of the 
first liullier exploration should be inmiediately undertaken. 

Thrombosis of the Lateral Sinus and Lateral Sinus Pyaemia. 
— Infection ol this -inns iki ui> as a Ksult ol the extension 
of inflamm.itoiy disease from the middle tar or the adjaeent 
structiut s. 

The thiiMnbus ma\- m mav not !'.■ s.-piic ; when. lio\\e\-er, 
it has become infettnl bv iiaiho,;;! nic tueanisms. ;;intial 
septic infection w ill m > in. 

The infection may in piimaiv. b\- ihe tliieit t xteiisieii nl 
septic Mischief throuKb 'bt masimtl antiimi and the i tils 
between it aiit! tiie lateral smus m ihe sif.;moid ;.;iiio\t'. ih. k bv 
settinf,' up a peiiiihlebitis. with a siibse(|uent lormation of 
clot in the cavit\- nl the sinus. ( )r a s,i(intiar\ thrombosis 

of this sinus will liilloW t Xlellslun ol ( 111! Ilflli the I a\-einoiis. 

inferior pi'trosal. or superior petrosal sinus, miiin.d .nulitory 
vein, the small vessels draining the tynipaiiK iavit\ "i the 
cochlear vein th. two last -mentioned vessels entering din < tly 

nili> ihi bulb 111 tin lati lal sinus tlint I . 



y.\ I UA( RASIAL COMriJCAnoSS 



193 



'J ludinhosis of the lateral sinus itself, so lonj; as the throm- 
lidsis is not septic, will \w attended liv no marked ^>-niptonis 
l)iyond lliosf of -~Ii,L;lit [)ain and sli^dit elevation of tenii i lattu'e. 
'liiis aitsenee of special synij)tonis is largily due to the fact 
tliat the tliionihosis is almost always accompanied hv some 
otln itliological state, as extradural aliscess or intlamm.i- 
tion of thi' mastoid, whith masl< s\'niiitoms tliat would otlier- 
wise make themselves oi;vious. When the clot has liecome 
infected hy jiatho^anic organisms ])enetrating its substance, 
thesymptcims will (Uvelop ra])iillv from the monuiit that any 
sejitic n^atter tind> its way into the lilood->tream. however 
minute the amoimt of this poison may !)e. Thus the s^'inp- 
toms of lateral sinus disease will lie. in its short preliminary 
stage, those of general illnos. with an ele\-ation of tempera- 
ture and jiain in the head, extending ])erha]>> down tlie side 
of the neck. TheM- symptoms uill, if followed liy a rigor, he 
atti nded by a ri-.e of ti'uperaturi' rarely less than 104-5'^ F.. 
though it may not exceed loj^^"^ V . ; tiie latter degree is 
usually the lng!u>t temperatiu'e ;ieeom])anviiig a rigor due 
to the formation ef a brain aliscess. At this time tlu' dis- 
charge from tlie ear will be lessened, or will even temporarily 
cease, on account of the high temperature causing general 
diminution of all secretion. As the (lot inthesiml^^ increases 
ui length ad traxtls downwai :s, the juitient. who already 
suffers Mom t eplialalgia. will now complain of pain and 
stiffness in tlie region of the sterno-UKi^tnid muscli . ami a 
careful paljiation in tlu' course of the carotid vosels will 
demonstrate p.iin and tenderness in 'liis region. '1 he exist- 
ence ot a hard cord like niass passing u.-wn towards thesterno- 
iLuuul.ir joint has been detected. 'I'liis is ( aused by the 
presence ot (lot in the internal jugular vein, or by a string of 
swollen lymphatic glands lying upon the vein. Gvdema over 
tlie mastoid |)rncess is jiresent in a certain nunilier of cases, 
and is (hie to ,i llironiliosis ot ijie einissory \'ein of Santorini, 
wliich Is lri'(iuenll\ found in the neighbourhood. X'diiiiting 

will UMially l>e .1 lu.ukul lealUie of llieiase. 

In lli( pK hiiiin.iry stages constipation is the rule, but as 

tllC C<1>( plogr(sses di.irihiea UsU,dI\' de\'elops, (iflcii ,U(Olll- 



{ 



I! 



Ill 



mi 



liiii 



194 II.lSDI"OK oi- nTSE.is':s oi- Tifi: r.\R 

panud l.y sfvrrr iilKloniinul (listurlnincc. a fact wl'irli i :,,iy 
tend to throw the iiractitioncT oil hi> guard, and c lusr liini 
to suspiTt typhoid ivxvv. Tho rose spots of typhoid, how- 
ever, will never lie noiired. Inep a^r of luadaehi siMrially 
if ill.' i)ain extends towar' 'he occiput, may W tafcen as an 
indication of tlie exten> .f the clot towards tlie torcnlar 
H.roi'hih. The rigors will be repeated frequently, and are 
usually followed by jirolnse j.erspiration. and all the syiuptoms 
eoininonly found in th. so-called typhoid condition become 
gra<lnally manifest. The -kin is dry; the pulse freciueiit, 
Miiall. and thready ; >ordes form on the lips and te.'th ; the 
helly is rt'tracted ; ihe breath has a sweet hut offensive odour ; 
anil'c.iUi(iuative diarrlKea is the rule. Infarcts will often occur 
in the lungs, wh.ich are ushered in by pain resi'mbling that of 
pUurisy, and cause a troublesome cough. Lateral sums 
l.y;eniia of this type may give rise to the sus}ncion that the 
patient is sullering from tlu' hypostatic pneumonia of typhoid, 
but a carebil examination will demonstrate that the disease 
is ])nrely local; after a short jieriod the expectoration ot 
prune-juue si.utum will show that the chest symptoms are 
ilue to a local septie pneumonia. Infarcts also occur in the 
various joints, especially the smaller one;,, and in other parts 
of the body. 

Ihe main points of diagnosis between typhoid feyer and 
lateral sinus pyiuuiia are the absence of the r(>se-coloured 
spots of tyi-hoid in this disease, tiie absence of pain on the 
right ili.ic In- a. the < liaraet.rislic teini'.ratme ch.ut of 
py;umi:i, whuh dilfers marl<edly from that (.1 eiiti'ric, together 
w'itli the history of discharge from the ear. Widal's reaction 
is negative in py;emia. 

Treatment.- -nt all intraeianial coini)li( .itiniis of suppura- 
tive otitis media, this is the one wliu h needs tlie most prompt 
and etticient relief. As soon as the diagnosis is made liiat 
(he patient is snfh'ring from l.it.ial sinus thrombosis, an 
operation slu-ulil be iminxnaicK- undertakrii. It consists 
iirimarily in exposing the sinus in tlie sigmoid suUus, which 
should be accomiilished by continuing backwards the bony 
V.r:!i'.!d. 'ormetl alter h-.ivinLI done a rapid ladicil operation 



IX Th'ACh'AXfAL COMPLICA TIOXS 



lo; 



on tlic iiKistoid antnini. A> ^non as thr siuuN is irailicd. it 
sliinild hv exposed for at k'ast ail iiicli. and tlu' \ismI care- 
fully ixainiiu'd with the linper. and if it i^ felt hard and 
clotted, ail incision i- made in its wall, and the (lot removed 
l>y ( tiretting fiiM in one direction and then in the other, until 
the blood {lows with a free stream. This hiemorrhaj^e is 
( he(d-:e(l liy the in^i'rti(ni of a >triii of j^an/.e. whi( h is packed 
in tif.,dit!y between tlu' sinus wall and the >kull. 'J he infected 
channel must he carefully clean>ed with antiseptics and the 
wound similarly dressed. If. however, the clot txlenti-< ii.to 
the ju,L;iilar \ein. or if tlu- opeiator is mialile to obtain a frii; 
llow of blood from the cardiac end. the juf^'ular \-ein must be 
exposed in the iieck b\- means of a loni.; incision down the 
anterior border of the >terno-mastoid muscle, and the \-ein 
lii;atured. if ;ios>il)le. below the clot. The \-fiu is then 
ili\ided. the (.lot leniowd. and an attempt made to s\-rinKe 
throu,L;li Iroiu the vein into tiie wound in the ^kull. If the 
o|)erator is unable to accompli>h >o much, it mav be better 
to di>sect out the whok' of thi' \-eiii. iiududing tlie ju,i;ular 
i>nlb. althou,L;h this (Xtension of the ojieration is , w under- 
taking; which is of considerable ma,miitudc and ditliculty. 
Hut before proccediufj; to add to the already long and se\-erf 
oper.dion. the probable effect on the ].atieiit nmst be decided 
uiion : therefore, unless his condition is sul'ti( ienth' good, the 
operator will be wiser if he postjioiio this joi' the pr( sent and 
waits on eyents. 



Lumbar Puncture. The following jioints. taken from 
i'urvis Sl(wait's 'Diaijnosis ol Ner\-ous Diseases.' will i)e 
o) assistance in i learing uji douottul points in diagnosis of 
intracranial complication ; 

The tluid is pnrul( lit or ( loiid\' in nieiiin.^itis. 

In sup)iinati\( meningitis and brain abscess with local 
meningitis, one t'liuls polynuclear leucocytosis. mostl\- pol\-- 
niorplis. 



Tiler 



(' IS a I': 



■eiice "t c.irb(ih\-<lr.ite< ni the tlui'i in nnninL'itis. 



In biain abscess without meningitis tliero is no leucocytosis. 
In stibactite or chronic meiiingili. one finds excess of small 

I iDi 111 u tl I tli^ 1 11. I '] I . II 1 nil.' < .1 w ^ 



iii 



hi 



C]iAPli:K XI I 
OPERATIONS 



i 



I. Minor Operations. 

MiN(iK (iiu'r:Uivc ■ ■ iism'cs uiulcrtakcii for the relief nf deafness 
and tinnitus have (me ,^( neral in'ineijile- the division of tlic 
-t'lutures 'Alueli interfile to jirevent tlie normal molality of 
the (i>-.ieular cliaiii. Siu ii t'xanipKs are tin- di\-ision of the 
ttiiihm of the tensor tyinpani. division of the posterior fold 
or lii^anient of the malleus, the division of the anterior liga- 
ment of tlu' malletis and of the tendon of the stapt'dius. iis 
well as the separation of adhesions. With the exci']ition of 
those minor operations already (U :<-ribed. ol)viously no delinite 
instructions can be laid down for 'he division of adhesions. 
Every adhesion which a]>]iears to havi' a deleterious influence 
uiiou tlie hearing sliould lie divided, more especially tlio>" 
atta(hing the drum to the long process of the incus, which 
must be caretull\- dissected off with a myringotome ( ur\-i'd 
on the tltt ; tlie frequent use ol intlatiou besides rar. laetion 
of an' in the e.\ternal nuatus. w to lie ( m ployed to pre\-enL 
readlu^iou during healing. 'I'lu'se ; mall operations are niori' 
beneficial when undertaken for the relie* of tinnitus than for 
the im]iro\emeiit of audition, and jiatieuL^ >liould not lie Kil 
toixjieci much bettev.nent of their lit aring. 

Paracentesis, or Incision of thb Drum. — The (xt« rnal 
meatus nui'-t be inigated with .in antiseptic solution and care- 
iiiil\' dried. If a geiier.d ai!,i>lheiie i> ll^(^l. tiie light may 
be carefully focus>ed on the ear before the patient is deeply 
unconscious, in order to a\did undue waste ol time, and 



especially .^o u iiiuuus o.vim 



IS I i S I u . 



1 IIV. Vii» > 



lilO I 4 Ulli 



U,(, 



OPERATIONS 



107 



required is a sharp-pointed myringotome. Tlic drum is 
jKM-forated posterior to the handle of th<' malleus, within a 
short (listanee of the jiostrrior fold of the nuinhrane. The 
inner tympanie wall slioidd not he tonehe'l. The knife is 
then i)assfd straight down from the superior posterior part of 
the drum to the inferior part of the luemhrane. dividing it in 
almost its whoh' length. After tlu' ineision the caiud is to 
1h' elcansed froiu all ])us and l)lood cither Ity means of sterilized 
wool mops or l)y irrigation, liie canal is then jiaeked with 
ase])tic or antisejitie gauze, tlie inner end of which shoidd 
touch the womul in the drum, in order to drain out all tluids 
Irom the middle ear. Tiie dressing requires ciianging as soon 
as the out(n" i-nd l)t'comes damp. or. in other cases, at tlie end 
of twenty-four hours. 

Division of tiie Tendon of the Tensor Tympani. This opera- 
tion may tie performed imder cocaine an;estiiesia. l)ut it is 
preh'rahle to use a general anicsthetic. If coeaint' he chosen. 
thi> anilini' jneparations mtist he employed, and strict anti- 
se])lic precautions are to l)e ohserved. An incision is luade 
liehind the handle of the malleus, commencing at the level of 
till' short process, and extending down half the length of the 
handle. A tenotome is now introduced, either ahove or helow 
the tendon, which is severed l)y a sawing moveuK lit of the 
knife. After the tenotome is rem()\'ed a cm\'ed jirolie sliould 
he inserted in order to ascertain that the division is comjilete. 
Healing of the wound in tiie tympanic memlirane will take 
place under antiseptit precautions in a few days, at the end 
ot v.Iiich time inflation shoidd lie enijiloyed in onl( r to obtain 
iinpiox-einent in hearing. The handle of tlie maliriis tends to 
resume its normal jiosition aftc tiiis ojHralion. in those 
cases in wl'" li tiie maliens is extreiiielv retracted i( may lie 
necissary to di\ide the tendon through an anterior incision. 
there not being sutticiiMtt space for a posterior one. 

The luumorrhage from 'liissiiglit oper;ition is rarely Iron' le- 
soiiic. .uii! mav lie ea>il\- ilh eki il b\' jiliigging. 

Division of the Posterior Fold of tlie Membrane. This pvo- 

Ceduie siiould only lie elllploytd wile:; llie stllK lui'e is ])roini- 

-.-...-.-.i .:•..' - -.^r -.r.-,1 --..i. ... ..1.. '.-.-.•.. ... .. ..!.. i .. il... i'..!.! '!"!,., 

ilviii. tliivl ^CvCi^il Liil^. tii.v.ie ii»llil»\vi!.ei*v i il liie ii'iti. liiC 



m 



I 



i ,1 



( !• 



198 



HANDBOOK OF DISEASES OF THE EAR 



incision must lie f'-om hciow. and iierfornicd witli a sharp- 
]Miintc(l t(nnt()nit\ 

Division of the Anterior Ligament of the Malleus. A shai])- 
]i(iintr(l ni\Tnig()t(init' is insnicd just htlow and in front of 
llic sliort i^rocc'ss. Tlic knife is tlnn forced u]iwards with a 
sawinp; movement towanls llie not( h of Kixdni. wlien tlie 
lii^ament will I)e felt to divide heniatli the knife. 

Division of the Stapedius Tendon. — T! c> li( id of ()])erati..n 
must lie (xiiosed li\- cnttin;.,' a flap in the memhrana t\ni]K:ni. 
svhieh will fold d(jwnwards. This niav he done by insert in,!j; 
the knife behind the handle of llie malleus on a le\-el v.iiii its 
short juocfSN dixitliiiL,' the membrane hoii/'-.iialh- ba(d<warils 
to the jieripluiA-. and then turnin'.; and euttin,!; downwards for 
nearly the same distane: . The slit^lit bleedin;,' which ensues 
nm>t be(h((ki.'i \>\ ^tiitle ]ire>sure. When the h;L'morrhaf;e 
has I'lkU controlled, and alter the remo\al of an\- blood-clot 
which ()i)scures the field of \ie\\. the tendon is ^t'en passing 
horizontallv backwards from the head of tlie sta]HS. like a line 
white thread. It is dix'idi-d. the parts tliorouf^lilv (deansed 
with antiseptics, and the woimd j^'entlv |)lui;t;''d. '1 he wound 
in the' membrane will heal with great rapidity. The ti'iidoii 
of the stapedius is di\ided after sui>]iura1ive otitis media, the 
))osterior jxirtion of the mem])rane and the incus being de- 
stroyed, the sta]>edius remaining in the o\al window, and the 
sta))editrs nniscle ha\ing thus ceased to jierlorm any useful 
function, whicii was to ]ire\-ent the sta])es being (lri\'en too 
far into the o\ al window win n tlie m,dleti> was drawn inwards 
iiy the Iciixir tNinpani, I'nder the conditions ]ire\aouslv 
deseribi il. the nms( le ijiaws outwards the anterior ]iortion of 
till' loiitpl.ite, anil a ilistinet impro\ement in hearing will be 
obtained b\->e(tion oi the tendon. 



II. In Suppurative Otitis. 

Ossiculectomy, including the Removal of the Remains of the 
Ossicles, Drum, and External Attic Wall, llu op. laiion ot 
ossiculectomy 01 i,i;iu,ill\- (oii>isi,-d in tlie remo\al of the 
rem. litis ol the (iinmlu.ul an^ nl the larger ossn les onlw It 



III! I 



OPERA TIONS 



I DO 



is now niadi' to inchide. in addition, tlie nMiioval of as much 
ol the cxti-rnal attic wall as can hv cut away and removed 
through the external meatus. 

It is an operation l)y which the surgeon attempts a cure 
without resorting to a radical operatio;: on the mastoid in 
troul)lesome cases of prolonged chronic discharge from the 
middle ear; it is cuh; to lie employed where the temjioral 
hone i'^ not carious, and it cannot be successful mrless the 
antrum be so situated that efficient drainage is possil)le. It 
should not. as a rule, lie pi^rformed until the patient has been 
undi'r trt'atment for chronic suppuration for at least three 
months. It is chiefly indicated where the patii-nt finds it 
impossible to givi' up his occupation for the length of tinu^ 
necessary in order to undiTgo the nrore serious mastoid 
operation, since a week's rest in l)ed usually suffices after 



a 



FIG. 



-INCrS CURKTTE. 




o.ssiculectomy to ])erinit his safe return to duty, provided he 
remains under ol)Servation and has the wound dressed 
regularly. 

The indications for removal of the ossicles may be taken 
to consist in : (i) A suppuration of more than three months' 
duration where ordinary treatment has failed ; (2) wlien sup- 
])uration has ceased, and the consequent cicatrization has 
bound down some of the small bones of the ear by scar-tissue 
and has rendered the patient deaf, if, in the light of known 
facts (see timing-fork tests), the aiual condition wUl be 
improved by operative procedures. 

Preliminary Prcf^arations.—Twcniy-Umr hours before the 
time ekcted for operation the ear should be thoroughly 
cleansed by irrigation with pero.xide of hydrogen of tiie 
strength of 10 volumes, after which it should be thoroughly 
syringed with 5 per cent, carbolic acid ; the meatus is then 
pluggetl witii a strip of gauze wrung out in the same solution, 



^ii 



"^fi 



200 



lIAXDnOOK OF DISEASES OF THE EAR 



I ii 



#!i 



the p.-mzo l)einL' K-ft in situ until tlu' time of the ojxTation. 
A p'licral an;esilu'iic is necessary, and tlie operation is ]ht- 
iornud witli tlie aid of rdlrrtcd light. If tlir reeumhent 
Jiosition is used, tlu' ojHTator nm-t luar in mind tlir altered 
aj)i)earanee tliat tlir drum will jir. smt. thr malleus ajipearing 
to lie horizonially instead of vertieally. After the ]nieking is 
removed, the ear must l.e earefully dried with j.iedgets of 
sterilized cotton-wool, care being taken to avoid as far as 
jHissible any injury to the lissues. which might cause bleeding, 
and so obstruct the view. 

Ol^craluni. A blunt-iiointed myringotome is now mserted 
in tront of or behind the short ])rocess of the malleus, and 
carrie<l in a circular diieetion comiiletely round the drum at 
its junction with the nuatus. Tln' line of incision nmst be 
kept as close to the bone as is possible, and eomi)leti'd at the 
opposite side of the malleus t. that on which the knife \\;us 
mserted. The knife is then withdrawn, and the malleus lirndy 
seized with a ].air of strong forceps- preferalilv 1. mann's- 
as far abow the short jirocess as is jiossible. The nudleus 
thus grij)ped is then drawn downwards and outwards, thus 
rupturing the ligaments and tensor tymjjani tendon, and at 
the same time renu)ving the remains of the mend>rana tympani. 
Many ojierators ])ri'fer renu.ving the malleus by Dtdstanche's 
e.xtracteur. 'I'lie looji of tins instrument is made to embrace 
the handle ot the iione. and has its sharp eiige upwards ; 
Uj.ward m(»vement severs tlu' tendon when the sharp edge 
strikes it. and the bone is then renu)\-ed by ])ulling downwards 
and outwards. The loop of an' incus hook is now inserted into 
the attic, so as to occupy the site pre\-iousIy occujiied by the 
liead oi the malKus. When in this position it is rotated 
ba( kwards. so that what rt mains of the heaii of th,' incus is 
embraced in the looj). and then by a downward and hirward 
mo\eineiit the incus is dislocated into theca\-nm tympani, and 
li not removed by the loop of the curette, it mav be cleared 
awav either by syringing or foinps. All bleeding is con- 
trolled either by a cotton-wool plug soaked in adrenalin solu- 
tion, or by irrigation with hydrogen jn'ro.Nide of Hie strength 
III lo vojimies ; pressure i> olten all that is reciuired. The 



!i 



l!'-L..„.-„.., 



OPERA TIOXS 



201 



external attic wall is now cut awav citlur liv moans of a tliiscl. 
a cross-cut dental liurr protccttd at tlic end. (»r l>v Krausc's 
ostcotonu'. 

The boni' sliould l>r ahlatcd uKirc ]>(istcriorlv and suju riorly 
ihan anteriorly, and an attempt made t() reninve tlie attic 
wall so thorouj^ddy that a probe t)t'nt at tlie tip and pa>sed 
into the attic may he witluhawn witliont encountering any 
resistance. The ca\'um tjanpani must nnw he iretted to 
remove all granulatiou tissue, and freily moj)])! . out witli 
Listers strong tltiid [vide Appendi.x) or pure carliolic aci<l. or 
pure carbolic acid and formalin (e(jual parts) ; tlie hr^t solutio-. 
is less often followed by facial paresis. The cavity is linally 
frei'ly irrigated ; the antrunt itself washed out by means of a 
dental cavitj' syringe, and Listi'r's strong fluid may be used 
for this jnirpose. 

The meatus is tirndy plugged with a long strip of steriliAHl 
antisej)tic gauze, care being t.iken that the [jacking in the 
inner jxirts is firmly done. 

After the operation slight vertigo may be coin]>laine(l of. 
This sym[>tom is commonly transii'iit, but it may pi'i'sisl for 
as long as two weeks, l-'acial palsy, mori> rarely than vertigo 
— also ot a transient character — may be a seijuence, and is 
due either to traumatism during the operation, or to inll im- 
mator}' swelling in the I'allopian c.inal. 

The dressings are to be changed as often as they become 
soiled, and the antriun irrig.ited at each dressing. 

The openition itself atlords e.xtri'mely satistactoi-\' results. 
Of fifty consecutive cases, no fewer th.in lortv-two were cured, 
and it ma\- safely be said th.it, with <lue cue, in no c.ise is the 
liearing-power diminished ; on the contr.irv, in nearK' h ilf the 
cases it is slightly iini)roved. It must be admitted th ii there 
is a liability for a cert, nn proportion of these cases to rel,ip>e, 
though this is n.)t a l.ugi' [lenentage ; and the oj)er,ition itsell 
may be considered, even when it tails in attaining its im- 
nu'diate object, as a useful prelindn.try to the radi( .d mastoid 
ojieration. 



202 



HA XD BOOK OF DISEASES OF THE EAR 



m 

III'. 



!i 



' ; ! 



III. Operations on the Mastoid Process. 

In'!ic,iii.,n> l..r opciMii,,,) ,„i {.W inast.ud m.iv W <livi<lt'd 
mlo tw,. great classes : {u) For acute cases, and (I,) tor chronic 
cases. 

{«) Acute Cd-scs. 

1. Acute ^ni)]>uration o| the ni.istoid antrum. 

2. Acute luherculous disease of (hr iiiiddie ear. 
J. lie/old's mastoiditis. 

I. In dl Acute Cases of Non-tuberculous Mastoiditis, and 

thos,. uliieh <lo n. < involve ihc^ whole or tlir major part ot tii,' 
cancellous or .vlhibr portions .,t the temporal hone the 
operati<.n shonl.l he that whieii is <lesignated ' Schv.'artze's 
operation,' 'vhieh will he found tullv descrihed on p. 20S. 
When a case ol acute suppurative nuddle-ear disease l)ecomes 
complicated by a secondary altection of the mastoid antrum 
the temperature, it it had ],reviouslv fallen, usually rises ; on 
the other lumd. if it had not fallen, it continues high ; cases, 
liowever, occur, especially the post-influenzal tvpe." in which 
extensive destruction of the mastoid is found unattended by 
any rise of temperature. Disch.arge from the ear may persisi. 
may have been extremely transient, or may never have been 
present. A slight rigor is occasional!)- noticed. The patient 
may or may not complain of pain in the region behind the 
ear. In its earliest stages the symptoms of involvement of 
the antrum are slight .and few. Besides those named there 
are .swelling and a degree ot redness of the posterior superior 
wall of the external meatus in its innermost iK)rtion. Tender- 
ness will be elicited by pressure over the mastoid antrum, 
which hesjusl l)ehind tlie auricle at a slightly higher level than 
the external meatus, and almost directly above it in chihhvn. 
lenderness of the same kind m,iv be louiid in other situations, 
especially at or in the region (,| the tip of the m.istoid. or at a' 
point about }, inch bel.nv the site o| ilu antrum, which may be 
taken to indicate either that the antru.n itself is not the'site 
"1 the abscess, one of the large c.-lls in ;he nKiste.j,! l.,,,,;,,- th,. 
■iliected area, or that the antrum i.s ii(,t the only sitiuiti.in in 



OPERATIOXS 



203 



which pus fxi^t^. The skin nvrv liic mastoid iimress 111, iv I'O 
sliglith' ivddcut'd. As tiu' disease ]n"i)gresses, oedematous 
swelling will take place, lirst nblitorating the post-auricular 
elctt. and afterw 's causing the auricle to j)rojec.t outwards. 
It tile patient remains unreliiA'ed, pus accumnlatcs lieneath 
the pcridsteum, and deep tluctnation m,i\' he detect(.'<.l ; he is 




Fic. 56. — SHOwrxr, trtcphinf. centrf.s for orFRATinxs tn' otitic 

I NTH A CRANIA I. I,l:SIONS. 

I, ("cnirr (]| tr('])hiiir ana Idi' ixpoMirc (it l(in))ciri)->|ilicn:ii<lal Inlto '. 
2, (cntic of ticiiliiiiL' area for iximsiire of lateral >imis : ;. 1 rntre 
of tre])liin(' area for ex]iosure of ( crebellum ; (, sjiine of llriile. 

iurther exposed to the danger ot the ]nis lindiiii,' it^ wa\- into 
tile cranial cavitv, with its attendant risks. 

2. Acute Tuberculous Disease of the Middle Ear. -In a( iite 
tuberculous disease of the middle ear, if the treatment ,idvo- 
cated Oil j). 137 is not successful in checking the disease within 
two weeks, an ojieratiou must be performed ; but in this case 
it must b(> the completi^ or r.idieal oju'ratii'ii, to which the 

cli>ar.mce ol disease. 



ill 



11 



t > 



t : 



i k J 









204 HAXDDOOK UF DISEASES OF THE EAR 

3- Bezold's Mastoiditis.— Tliis condition will be iound fully 
di>scrii.c.(l r.n p. 123. Who.. Hie surgeon is convineed that 
liiere is jnis in tlie ni.is. -id, and is ot opinion, from the clinical 
signs, that the disease tends to thr condition known as 
'Bezold's inastnjditis,' he must sanction even less delay than 
it pus were confined to the mastoid antniin. 

Post-Influenzal Mastoiditis.— One nature m this variety of 
disease is that the inicrobic (nniiiiKinly diplococcij invasion 
ol the antrum i> not always preceded by a discharge from the 
ext.-nial meatus : and another, that it the antrum is not opened 
surgicallvat the earliest indication oi troul)le, there is a greater 
'iskol serious brain mischii't than in ordinary acutemastnjdjtis. 
Seenndarv deafness and mastoid j»,un are complicitinns of 
"ithien/a, and should cause an immediate inspection ot the 
ear and mastwi,! ppM ess. tenderness over the mastoid !)eing 
■ I sulluieiii indie .itinii |.,r immediate oper.ition ; the jMrt Iving 
''innediatel\- subi.ieeiit to the tender area ought to ]k- e.ire- 
liillv e\p|.ircd l,,r ;,ii isohited purulent focus. A iioinial m- 
siibiioinial temprratmv must be ignoivd in post-intlueiizai 
'•■i-i -, as there is open nothing m the trmperatuiv to point 
to the least danger, . vn when pus 1^ lound in the si!-,|„,ij 
groove. 

(/.'J Chyiiiiii Ciiscs. 

rNI)!C\ri(i\s l.-,,K Ol'IK.MIoN IN ClIKoMC SlI'lT K A 1 I Vi: 
"'"■'• '^^'■^ ■ -\'"llte eX.ircrb.ltlolls o| elironit sUpplUMtive 
middle c.ir disiMse. 

In .hlouie suppuiMtuv <lise.,se. wheiv skilled tiv.itmeul 
' ■'"■"'"-\' '■•iiiied out lor ,1 re.ison able Inigth oi tim,' ii.unrlv. 
•''"■"" ^'^ iiionihs has l.iii,.l ; \vh, r,.. m , hiidi.u .nid \omig 
■'dult>. ,ideiio|,I ve-.'t.itionshavrbrcu removed u It liout .uriiig 

"''■ ■'""■'' '^'■ippui.ltlon ; ,,lld Wilrle Ihr llimnr ,,per.,t|ou n\ 
osMi ll|.(toi||\- .ippe.iis to oil, a MO hope o| , mv. 

Constantly recurring .in.irks o| suppuMtmi, m Hie middir 
ear. esiK'cialiy if associaird wiih L;i.Mmr,,oi pam. 
I'aci.d |.ai.il\-.i-. Ml ^ In, ail. sii|ipm,ituv run, In,, .n^. 
liecui 1 ing polypi. 

<'liol,.sie,it,„,,attuis disease ot ih.- .iiiiiiim. 
I. lOi.ii \ertig<» on syringing. 



Ill* 



1;! 



orr.RATioxs 



2U5 



Persistent mastoid pain with sui)i)urati(>n. 

Contraction of tiie externa' meatus, or tiie presence of .in 
exostosis occluding the canal, when suppuration is present in 
the middle ear. 

Mastoid tistuhe. external or internal. 

Necr>;si£ (,f tlie temporal hone. 

Tuberculous disease of the middK' ear and lemitoral bone. 

As a preliminary to more extensive oi)erations undert.iki'H 
for the relief <>i intracranial com[)lications. 

Acute Exacerbations in Chronic Discharge. In a case of 
chronic suppurative otitis media, with \erti,L:'> and jierhaps 
sickness, tenderness will usually be elicited o\'er the site ot the 
antrum ; Literal nystagmus is occasionally present, and in 
most cases there will be elevation of the temperature, though 
pyrexia is by no means constant. Swelling of the posterior 
su|ierior p.irt ot the external mi;,,LUs is sometimes present, 
while, in other ca-es, all discharge will temporarily cease. 
Tenderne» over the mastoid antrum in chronic caNCs is of 
itself suriicient indication tor the radical o[ier,ition ; much 
more will it be so if accompanied by any of the above 
symiifoms. 

Facial Paralysis. -This mdicates a necrosis m the petrous 

1 e, and il left untieated is a frequent jirecursor of extension 

o| the disease to the meninges of the bniin. .ind so imperatively 
tlemands earlv o)ier.itive interlennce. 

Cholestealomatous Degeneration, it liie ittii done be 
involved opi'i.ition may be clel.iyed imlil tiie conduion h is 
I'loved incur.ible b\- the othi'r metliotls when el'olote.itom.i- 
tous degeneration has.itt.u ki d tlu' acce>,M>ry cavitieMil the ear, 
and an attempt to obtain a cure by means ot solvents, etc., 
has t.iiled. 

Lateral Vertigo on Syringing may l)e taken to mean that 
the muiibi.inous external seniK ircular canal on th.it side is 
expo>,ed by ero-,ion ot he bone. 1 iiis exposure o| tlie solt 
I'arts ot the l,d>yiiii!li is u-u.iliy a su'hcient mdicition tor 
o|ier,ilion. 

ill Persistent Mastoid Pain the (object oi (.pei.ition m.iv be 
more to ulieve p.uii ih,.n to cure the disi harye. 15ut liiis 



2or, 



ff.ixnuooK OF Dfsn.isns of thf far 



s-?i 



■i 

! iii 



il 



is never an indicatiun lor o|ierati(>n when su|ij)ur,ition is not 
])resent. 

Contraction of the External Meatus, with the jnesencc of 
suppuration be'.iind tlie obstruction, gives rise t(. a condition 
which 1-. probaljI\- unequalled in gravitv. as a steady destruc- 
tion of tissue v.-ill proceed unattended by any sj-niptoni 
sutlicientlv marked to amuse the apprehension of the ])atient ; 
tlie uio^,t trilling [.■brile state, ci the slightest actite iullani- 
ni, I torv condition in the region of the ear, may lead toaraindly 
fatal issue. 

The Choice of Instruments for Operations on the Mastoid. 

In operating on the mastoid, one may choose between tinee 
general methods of oper.itivc; interference, one with the cutting 
gouge, another with the hanuner and chisel or gouge, and the 
third Iiy me.ins (,1 tiie bmr. whether driven by electricity or 
by h.ind powi^r. The burr ,ind the cutting gouge have 
adv,int.i,ges over tile method in which the hammer is employed, 
which should render them so far superior as to practic.dly pro- 
labit the emplovment of the hannner in performance of 
ojH'r.itions on the m.istoid process. 

In ,dl methods of opnuating the same amount of skill can be 
acquired, but i'rob,d)ly the cutting gouge is the more easy to 
map.ipul.itcmd.dthunghm the h.indsofa novice it m.iyr.ilher 
tend to slowness, yet the <l,inger .ittending on its use is l,ir 
less tlrin tli,it ol the chisel and ii.nnmer. There is t,ir less 
dang.r ol cutting inj^o ini|»oit,int structures, and al.o if the 
hanuiier is u-,rd a niodilied lorm of concus-ion o| th, br.iiu is 
c.iused, ,ind many patients siiffia lor a coiisideiMble period 
Ironi .1 prolong.'d conv.descence. which seems to be largely 
due to the .iiuount ol concussion ciused bv the oper.ition. 

I'ait bv no me, Ills the je.ist import. int .ispect (r| the choice of 
instruments is th.it, ,ipart Irom the concussion, tjie .imount of 
shock is m.it.'riillv inrrcised, ,ind. .is will be sten by tiie 

'•^'■"^ ""• '"I'' 1-I-' lures In: i,)ij.« ,1, ,,,,.!i ^^{j.,,1^., „f (,j^, 

iiamiiier ,i d:siui. I shock is given {n the p.ilient's nervous 

* "■ '^"'" '''''v U'l I.i'c.ii.r.l I'.UMMi., Hnl,-.l, MiJu.il Fiinuil 
Mav a. i(j' 2. I) luiiii ' 



in 



OPERA TIOXS 



TO7 



svHtfni, wlioreas if no linniner is used the sliock of the opera- 
tion is minimized. The more prolonged the operation, there- 
lore, with the liannner and chisel, the greater the amount of 
shook, as well as of concussion, that is experienced by the 
patient. 

In employing the cutting gouge, such as is figured in this 
book, the i)rincii)al ])oinls to remember are that tiie wt'ight is 
the piece of bcme to be removed, tiiat the fulcrum is the point 
at which the bevel staits from the main line of tlie instrument, 
the power being, of course, the hand. The g"Uge sliould be 
helds() that the head rests comfortably in llie iiand. the index 
finger lying along the gouge, which linger sliould [imject 
siightlv beyond the edge of the gouge, at an\ rate until the 
operator is thorouglilv practised in its use. It is better nut to 




^ 



^ iiinnHli 



I'IG. 57. — L.MiYKlNTlf r.OCGES. 



make a directly straiglilforward cut, but to slightly twist the 
gouge as one cuts forward, something in tiie manner of a screw. 
Hut. like ,dl instruments, it is better as far as possible that the 
oiH'r.itor atfjuires mhuo little jiroficiency on the .uliver, or 
even on a ])iei e ot hard wood or skull. 

The obji-ctinii to tlie burr is the slow ]),K'e ,it whicli one h is 
to work iiut tor all th.it it is an e\tremel\' usetul instrument, 
and one u lii( ii will give coniicU-nce tre(juentl\' to nu'xperienced 
operators Hut if the student is re.dly desirous ot domg good 
work, no Ix'tter reconunend.ition can be given witii reg.ird to 
the ( iiiiiee o| instruments tiian lor th.it individu.d to .ittempt 
to see as many dilferent surgeons as possible i)erlormmg tlie 
operation, as tiie tecimiciue of each will v.irv somewhat, and 
those points which appr.d to iiiin may be seh cted from cell 
one. 



2o8 



iiASDtu)()K (>/■ Disi- isi:s ()[■ Tin: i:au 






Simple Opening of the Mastoid Antrum. 

Schwanze's Operation.— Ihis opcTatinn iiicludes tlu> opening 
lit isolated abscesses in the mastoid, as well as abscess of the 
antrum. 

Tile operation about to be described is one that is i)er- 
tormed only in acute aiscs. and is not suitable tor chronic 
disease, as il lias tor its oI)ject the opening,' and drainage of 
an acute abscess. For this reason the incision in the skin is 
niucli shorter tJian that required in the radical ojjcration ; 
the bone is not removed to the same extent, and neither the 
bony nor cartilaginous wall of the external meatus is inter- 
tered with. It may hapi.en that the whole mastoid process 
may \)v disorganized, or that pus has even iierforated the 




FIG. 58. — M.^STOID GOUGE. 

TlH.se goiij;L-s arc inadf in si't.s of four, all fitting into tl.e saino handle, 
or tliey may lie hul sejiarately, with nuishrooni handles. 

deeper aspects of the bone, and travelled along the fasci.il 
I'lanes ol the lunk ; m such cases the area oi hnnc removed 
in eradiciling the disease mav I>e considerably greater than 
that which is u-uil iti i!i,. radu'.d operation. However, even 
under sueii e.\cei>tionil ((iiidiiions, it j., not necessary to 
ivniove tlie jxKterior w.d! of the niealus unless tiie disease 

1k' tulu'Ic uloUs 

rrdnnnuiry Mc.i'^iirc's. I'he surrounding skin should be 
shaved f.ir some 2 or .5 inciies from the ear. and carefully 
w.isiied with soft 01 ether so.ip. the extern. d meatus irrig.ited 
with 1 m .;.(iu() livdrarg. pe.rhi,,i. o,- 5 ,,er cent .-..rlx.lic, 
and iMck.,1 will, \v,.t .intisepiie g;iuze ; the ear and shaven 
are.i are well wasjied w,tli tile s.mie antiseptic, and a wet 

ailll-el'lK dlessiug .ipplied ; tills should I)e ,!on,.. i! i.e^ss-!;!- 



OPF.RATrnXS 



209 



at least twelve hours before the time of operation. A thorough 
cleansing is carried out when the dressing is removed under 
anresthesia. just before the conunencement of the operation, 
and thr ear well s3-ringed out with 5 per cent, carbolic acid 
solution. 

The skin incision should be vertical or curvilinear, about 
I J inches in length, with centre lying over the antrum, 
or spcciiil site of jjain. The tissues are divided down to 
the bone, and periosteum raised with a periosteum elevator; 
the sides o( the wound are now held apart with retractors by 
an assistant. If the antrum be the seat of disease, the bone 
is carefully cut aw.iy for an area which should be limited 
anteriorly by the bony meatal wall, and sui)eriorly by the 
posterior end of the tempond ridge; and the ojiening in the 
bone should not l)e 'arger thin is requisite for comfortable 



^ 



K 



111",. 51).— CHISEL POINTS. 

It is wvll, wlion ruttin^j; iiwav tin- iiostcrior iiu'.ata! wM .ind rxtc-rnal 
attii w.ill, to use a lui,'li-]ntclK-il mttlri'; c(t^c like tliat on the loft. 






W(,rking. The guide lo the antrum is the sjiine of 1 [(-nle or 
the jiosterior superior spine ot liie meatus, whik' a line p.irallel 
to the po-,terior >uj)erior i>nt ol the 1)(M1\- meatus will five 
the directiMU for the jxissage which must In- m.ide in tiie 
bone in order t^ op,ii the antrum. When the dejtth of J inch 
h,is been re, h lied, cire must l)e exercised that the faci.d 
nerve be imt injured. This accident will not dccur it the 
centre of the wnund corresponds with the lunction of the 
superior and postcrinr w.dls of the nie.ilus. and it the exc.iv.i- 
ti"!i be c.inied out without rashness, the hone bring removed 
in thin films The e!iN<l, ii u^. d, nnist nut be diiven in i>er- 
pcMidicularly. Th, suitace ot the wi.i;iid is \n 1),. gr.idn dlv 
nil.irged superiorly, if neces-,arv, so th.it t!ir pnMti-r m.iy 
' '."■ • I tint, aifv'i i ' ; w ; ;t %i't .1 j"ii.-» .-»v\i i l iU i 'n v > m i^i.i 11 1 i \' 

«4 



m 



aio 



I 

I M 



! l* 



I I'l 



ll.1M>l:(HiK 1)1- /)/,sy .I.s7;.s- oi- Till- l-.llf 

Used, ;iiul wlun it i'iit(>rs the antrum llic cliannel 
sii <il)taim'(l is caivtullv cnlaij^'ed until tlic wln-k" 
,-iniruni is cxpnst'd. An incision slmuld imw be 
made thidugii tlie pdsterior ])art of the drum, 
and rn ;intisei)tic sohition syringed tlu^ough the 
meatus into the woinid. and 'I'icc versa. All 
jiartielt's ot cHseased tissue are earefulK' removed 
from tlie antrum, and any diseased cells by 
mt'ans ol the cru'ette, search being made for 
small >inusi's in the bone leading to isolated foci 
ol disease; thr whole wound is swabbed out witn 
Lifter's strong solution dusted with iodoform, 
or tilled witli iodoform emulsion, and jiacked 
with antiseptic gau/;e. The skin-ilai)s are now 
sutured t<'gether, with tiie excejition of a small 
]>ortion towards the lower end of the wound, 
through which the ( nd <if the dressing protrudes. 

Sul>-^equent dressings consist in keeping the 
me.itus cle.m. bv means of carbolic acid douches 
and caieful plugging with antiseptic gauze, until 
all discharge h.is entirely ceased. The wound is 
allowed to granulate from the bottom, reducing 
the g.iuze ]ihigging as occasion requires, but it is 
not necessary to allow the wound to be entirely 
tilled ui> betore allowing it to cicatrize over, so 
long as no discharge is jiri-sent. Tlu' c.tvity is 
|),ickrd with nii.Ked iodofoiin anil boric acid, or 
tilled at each, dressing with iodoform emulsion (see 
Ai)pi'ndix). 

Operation in Bezold s Mastoiditis. 

Vlt is well to bi'.ir in nnnd that bi'iore perfora- 
tion of till' wwwv t.ible ot the m.istoid process can 
\.\kv place eel tain anitumic.il iH'culi.irities must 
I'l s- exist. Such a ondition cmnot occur unless the 
si-.akchi:r. mastoid I'rocess consists almost entirely of (clIs, 

with the uunimum .im^uut o| dijilor ,ind a irLitivi'K' thm outer 
.1 11 .1 1 It ;. ,,,, ,, , .1,1. I,.,,,,. I <K ,t ;■■ ii, ...... 



\. 



OPFRATIOXS 



211 



several cells of large size communicate with each other and 
with the antrum, one of these, more constant than the rest, 
being situated over tiic digastric groove in the under surface 
of the mastoid bone, and merely separated from tlie groove 
by a layer of bone scarcely as thick as an egg-shell (Fig. 14). 
I'us gaining entrance into the digastric fossa may find its way 
into other abnormal situations ; tlius, for instance, it may 
present at tlie naso-pharyngeal extremity of the Eustachian 
tube, burrow down the neck beneath the sterno-niastoid. or 
ajipear behind this muscle in the suboccipital region. As a 
result, however, of the more general knowledge of aural 



of 
IfenLe 




iti 



: 

i- 



lie. (>I.— LKI T !:.\Ti;UNAL MKATl H, SHOWING Sl'INi: OF IIKNLK. 



disease, it is rarely that we find cases so far advanced ; but 
the whole mastoid will more frequently be found full of pus 
and gramiLitiim tissue when the ojieration is undertaken, 
especially where p.iin was previously comiilained of on pressure 
in the region of the dig.istric fossa. 

Ihe same i)iehminarv treatment is necessary 'ith regard 
to antiseptics .md sh.ivmg that h.is Iven described for f)ther 
operations 011 the mastnid. An incision to i . bone is m.ide 
commencing just .d;ove the insertion of the auricle, and is 
caiiied crescentiially b.ukwards well witiiin the hair margin 



am 



! hrouglit down il nfcess.ii\- info tl 



le nee 



\V 






I 



? 



len 



V 



f^^ *l 



212 



irwDiiooK or disf.ases or riir. ama' 



tlie bone luis been exposed, tlie cortical portion should be 
rajjidly and freely removed, when pus will be found in most, 
if not all, of the cells ojiened. By means of forceps, curettes, 
and gouges, all diseased tissue should be freely removed, 
no matter how wide and extensive a cavity such radical 
measures mav cause. It may even be necessary to remove 
the wliole of the mastoid proci'ss and to lay bare the lateral 
siiujs lor ^omv K'ligth in order to i-emow all tr<ices ot the 
disease. The antrum should he sought for, hut il the siu'geon 
camiot successfully differentiate this cell -a (I'tt'rmination 
bv no means always easv under these conditions -the bone 
is to be removed in order to aifonl an entry into the attic. 
The mendirana tvmp.nii is now freely incised, and the middle 
t'ar and attic vsaslied out with an antisejitic solution, and an 
attcmi>t made to wash through from the jvist-auricular wound 
into the txanpanum. The whole of the bottom ot tlie cavit\- 
of the tempor.d bone is freelv mop[)ed with one ot the strong 
antiseptic lotions recommended ])reviously. The wound is 
now to be dusted with iodoform or iodoform emulsion, filled 
with antiseptic gauze, and sewn up, with the e.xce])tion ot 
a small portion of the lower angle to permit of iilugging, ami 
the meatus jilugged to the bottom. The treatment subse- 
quent to the reniov.d of the packing consists in the insertion 
of a drainage tube, and at each dressing the cavity is simjily 
Idled with iodoform emulsion through this tube, which is 
shortened as re(iuired. The external meatus, if pus still 
]Hi>ists in this direction, is irrig.ited frccpieutly with antist-|)tic 
solution and ]>higgt'd. 

Pus. when i)resent m aiu' "ther situation, nnnl be ev.icu ited 
and \\\v c,ivit\- treated b\- ordinary surgic d procedures, 

.Mtliough the amount of Ixine removed in these cases is 
vei\- large, iu'aling is exlrt'meK' r.ipid and tlie consecp.U'Ut 
deformitv verv slight, while the hciring is but rarely alfecti'd. 
il, .dter lieahmr. tlicre is an unsightK' po-,t-:iuri( ul.ir di'lui'mitv. 
sulx ut.ineous injections ot i>,ir,i I fm wax may be u-^ed to restore 
the norm,d contour of the p,»rt. 

It is now r.ire to lind a iiermanent opening behind the ear 
alter a m,l■^toid (iiier,ition, though tnrmerly this was l)v no 



liL 



Zd.su 



OPERA TlOyS 2 I 3 

means iincdinnion. Should such an upening unlortmiatoK- l)e 
left, a plastic operation is required to close it. 

The Radical Mastoid Operation. 

During the last two decades operations on the teinixiral bone 
luive been so much improved that it is not ])racticablt' in a 



11 




'4 



if ' 



MC. ')J. — Tin: INCISION FOK Till; KAIHCAL Ol^ toMl'l. il MASrOll) 

Ol'i RATION. 

work o| this si/e to ap]>ortiiiii due credit to those workers 

through whose skill and inginuit\' we have obtained the 

present excellent results. It is customary to give the name 

' radical o|n-ration ' to one which is intended to remove the 

w hole ot the disease, and at the same time to throw the middle 

.1.1 . . . ■ . 

viil, ilic CXlcm.ii iiUalViS, Uic .lUR. aini .mliuiii uiio Kiie iaigt: 

cavity. 



!t 



in 






214 



iiASDiiooK OF i>isi:asi:s of the far 



Prcli))ii)iary Pycpanitiuiis. — 'llie IrmcI slmuld be shaved for 
2 or J inehes from the ear. The skin ot the ear and of the 
side of the head, tlie neck, and fare are !.> be thoroughly 
washed with ether soaj) and well serubbt'd A\\ a nail-brush 
tweK'e to t\\i.'nt\'-four iioiirs before the time of o[)eration. 




Fir.. TiV — Till i:.\Kl.irK st.\('.i: of tiif. k.miical M,\sr<iii> oi'I.k.v 1 idn. 

Tlu' liniic lias liccu cut awiU' to show the mctlioil ailopt'Ml in iiittinu; 
down to tile aiitnmi. Tlio car is lichl lorwaid hy a loo]! of t'andayc, 
passed throut^h the external nioatus. 



At the s.ime time die external meatus is well irrigated with 
5 per cent, carbolic acid. 

The e.xternal ineatus is jiluggeil with .intiseptic g,iu/e soaked 
in a lesser strength of carbolic solution, and a moist antisi'j>tic 

At the time ot ojieration the parts are again we'll soape<l 



ori-h'A rioxs 213 

and SL'-ublx'd, and treated witli antiseptics in tlie usnal wav ; 
}. j)er cent, lonnalin is a most usetul solntiitn. A sterilized 
towel, or one soaked in z ]icr cent, carliolic acid, is now 
bonnd round tiie head in such a way as to enclose all the 
nnsliaved portions ot the hiir\- scilp An incision is then 




1 



Fic. 64, — THI-: AXTr-iM oi>i;.\'i:d. 
The l5onc iK'twccii the antrum and meatus is the ' Ijiad'^e.' 

made, conuni'ncin!,' ' inch ahovi^ the supeiioj- anterior insi-rtion 
ot tlii^ auricle keei)in;3' the incision within the sliaved edge of 
the hairy scalp, but at the bottom curvir- ' forwards to the 
.i|>i'.s. of tile mastoid |)rocess. The incision must be cul.ui< ous 
lor the first inch or il inches, but in the rest of its extent the 
knile is I'assed down to the bone. The re.ison for thi-^ ditfer- 



V liv (.. HI tliV (lllLeilV'i .tim Mij'tll'M j»,ilt. «'l llli: llUl^iWll iri LO 

avoid divitiing the temporal fascia and muscle. The tlip 



i l 






2I6 



II.WDIIOOK OF DlSHASliS Ol' Till: I.AU 



|i 



' f 

* 



VM 



marked out, witli the whole of the subjacent tissue, inchiding 
the ]>eriosteum, is dissected forwards and all bleeding-points 
secured. It is advisable that ever}- vessel, however small, be 
picked up. as oozing from the tlaj) materially retards the later 
steps ol the operation. The surgeon now defines the posterior 
and sui)erior edges of the bony meatus, and by means of a 
small elevator or probe sei)arates the u]i])er and posterior 
Jtarts of the cartilaginous meatus from the bony tube. The 
next ste]) is to divide the cartilaginous me.itus into anterior 
and ])osterior halves by ir.eans of ])arallel m<'isions through its 
upper and lower walls, these incisions being carried well up to 
its junction with the skin of the concha. A i)iece of b.indage, 
previously sterilized, is passed through the external meatus, 
and has its ends knotted into the form of ,i loop. This is 
given to an assistant, who uses it as a retractor, .ud pulls 
the external ear forwards. It is better now to tletine the 
l)osterior superior meatal si)ine (p. j), as this is the anatomical 
guide to the antrum, whit h m.iy be reached by cutting through 
the bone ])arallel to, and closi !y behind, the posterior sujierior 
angle ot the bony meatus. 

'Ihe bone is now attacked either with a gouge, chisel, or 
el'ctric bu' i If doi e by one of the two former instruments 
the process should be commenced on a level with the floor of 
the meatus in such a way as to remove the cortex from an 
area of about i to I inch in vertical diameter, and J to \ inch 
in antero-posterior or horizontal direction (Fig. ()j), cutting 
away the posterior wall ot th(- canal and ]>art "t the sU|;'rior 
with the rest of tlu' bone, working gradually inwards, uuh a 
slight direction upwards, liaving the centre of the cavity at a 
point corresponding as nearly as possible wifli that originally 
occui)ied by tlie spine of Henle. The posteiior curve n{ th ^ 
bony o]K'ning should corresi)ond to the curve of the skin 
incision, ;\nd should l)e limited .ibove b\- the posterior jvirt 
of th(> tcmi)ond ridge .dl'idcd to on p. 4. As the surgeon 
cautiously works his way inwards, removing as lie proceeds 
the entire posterior wall of the meatus, together with a con- 
sideralilo a.m'junt of llic suiHri's! h:' '.h.ii-.'.h! i-ti-^-. ■. *. i\-.. 
di^t.mce he still lias to traverse by means of a small nu'tal 



oi'ih'.rrioxs 



217 



hook —as a straliisimis hook — -or bent probe passed into the 
aditus. This will intorin liini ol the anionnt ot lx)ne still to 
be cnt awaj', and siiow hiin tiie direction in which to seek tor 
tlie antrum. He will do well to employ this precaution more 
tr'qucntly as the wound becomes deei)er. Wiien the antrum 
h.>., been ()])ened (Fig. ()4), as will be ascertained either by tlie 
exit of pus, or by the direction and depth to which a steel 
pus-searcher can be inserted, lie will ])rocee(l to enlarge this 




I'IG. 65. SUCTION OF LEFT TF.Ml'ORAL nONK S!IO\l ING TllT, C.WITY OF 

Tin; ANTRUM AND ITS KILATIONSIUl' TO THIC KXTICRNAL MEATUS. 
THE CAVITY IS CMSl'ALLY LAKGK. 

A, Antrum ; .1/, head of ni.illrii^^ ; /, body of iiiLUs and sliort process. 



opening lorwirds and upwards so as lo dehne that portion 
ol the posterior meatus which bridge-, over the aditus, and 
which }-et r^'Uiams to be removed. It is customary to sj)eak 
ol tliis n-maining ])ort:on ot the external nu'atus as ///(; bridge, 
and it is this ['or Jon which next has to be removed. This c^ ~ 
also l)e d<inc by ineans of a small pair of bone-forceps or by 
means oi liie mallei and ciiisei, and it is weii ior mexiieneiued 
(H)er.''i "s to insert a few pieces of sterilized sponge under the 



i 5 



pi 

I'l > 



ii 



21"^ n.ixnnooK of D!sr:,isi:s of tih: f.ar 

Wuliiv in nnl.T t.> pn,urt from injury tlu' cxtiM-nal semi- 
cirnilar r.m.il, whim lies ininiediately bt'm>atli iliis bridi^v of 
l)oiu'. If a l)urr isnsdl it must haw a i>roti'rtc(l ( nd, in ord' r 
tliat llir l)ridi,'c may 1h" (hvitlcd witiiout dama;^'c to the dcup'jr 
partr^. 

W lirn thv o|icratMr lla-^ hcmmc thoroiigiily ctflciont in tiic 
usi. ,,f tin. cittiii.c; f^out;.', lie will fmd the lurcssitv for tlic 
i'mi)loymrnt of \\\v h.imnicr and cliisd Un- the n-m.ival ot thr 
Inid^'c <iuilt' unnccvssary, and that he will U- ,d.lc to < ,it the 
whole p-.rtion awav witli the >mallrst of the tjoui/cs 

Alter havin.i,' oprm^d hvely into the antrum, and cut ,:way 
all the l>Mnc ovcrlx ini; the remnant of the so-railed Imd^e, 
the Milter attic w.ill should he cut away .is lar as jx-^srole 
with (he Miialler .t^nuge, Ix'i^inniiig at the t3-mi)anic n,, .f^'in. 
ihis i-, rather a dillKiiIt thing to d( scribe clearl\-, i)iit wuli 
a little practice e\-en that small amount of hammeriiiqdther- 
wi^e U(|uired can be -aved, and prub.ibly lime is saved here 
as well ; th(.ii.i,di (.per;, tin- for rapidity is a thin,^' that should 
not ])■ ..ttempted, but it (juickness comes with practice so 
niU( li the better. 

Inmiediatelv beneath t his bridjL^e r-vith tiie patient Iviuf,' on 
Ins side) lies the proiection farmed l)y the ii'.ri/ontal semi 
cii( ular cinal, and tlu facial nerve passes (hiectly outwanls 
and then downwards lying in the small iirojection o| boiielctl 
Ih'Iow ,itt(r the removal of the bridge h is now well to 
r. move hy means ol a j)air ot hne forceps any remains there 
ma\- be .,1 the (.ssi( les. Small portion^ of sterili/ed sponge may 
be pa( ked into the attic and its e\t( inal wall cut away by 
meaiisdi a ( hisel ;an o\m1 l>inrma\- be |iicleried. in which Case 
the pie( cs (., sponge are n( i re'iuilcd jhe exteiu d attic Wall 
must ]><• so hill\- removed ihat a bent probe intiodM. ed into 
ill'' •'"" ■'"• diawii outwards meets wiili no obsiriicti,,ii. 
With a line probe ( aieful search, is m.ide for sin.Nes le.iding to 
diseased are. is not vet e.vposed. It aiiv are hniiid thev must 

'"■ followed up (MielulK-. Small sinuses .11,. sometimes seen 
in the eXtelllil seiiii, II, 111 II (Mllal, llloK l,irel\- 111 the pos- 
'■''"' '^ I' l"^ seM'iiii seen III IIm^s,. op, r.itioiis SlK h simises 
-li-llld, howevel, 11.. t be ,ilhel pK.l.cl , ,i |(,lIow,.d Ui> With 



H 



()Pi:i{.iTio.\s 



219 



thr Imut ;m<l cliisrl unless tlu'iv aiv SN-inptoins wiiicli have 
K(l llie suit^ei'ii to believe that the ial)yrintli is .il^o the seat 
of suppurative disease. Destructiou of the 1' ly rooi of the 
attic should lead to a caietul search for any jierforation lif 
the (hua in the inuuedi ite iiiviroiunent. as a cerebral abscess 
may discharf^'e its contents 1)\- this route. With the jL^'oUf^e, 
chisel, or ilental burr the cavitv is rounded off ,is well as 
pos-^ible. When there is a desire to inspect full\- the cavitv 
ol the middle ear on account ot s\-mptoms i)o; -tin.L; to in\-olve- 
ment <ii the labxriinh, the posteiior wall of the meatus, whu h 
now ai)pears as an inclined iilaiu, must be cut aw,i\' m'>re 
comjileteh-. keepiiit,' the cut surfaces ilush with the meatal 
floor, and workiuf^ inw.irds until the level ol the Hour of the 
aditns is almo-^t reached. Here lenticular ca.rc' is !iece,^,ir\' 
not to wound the l.u i.d iierve. It often happens ihuin;.,' tlu' 
o[)eiMtion th.il ,iiuio\',ince is experienced from l>leedin;,' \'i ssels 
in tin' cut Ixmy surlace. i'his ma\' l)e innn"di itel\- remedied 
by crushing; a little sterilized w.ix into th ■ bleeding orilice. 
All f.;ramil..tion tissue, to^jetliei- with diseased mucous mem- 
br.iiie in the middle I'.ir, must be remo\-cd Irei'K' with ,i curi'tte. 
In I, let. il it is !)ro])oscd - bsequt-nth- to eniplov skin f,'raf tin}:;, 
no |i.irtiile o| niucou, membrane must i>e left behind, as it 
seiiou>ly inteileres with the successlul tjrowth ol the ,1,'ralt, 
esiH'ci,il!\' in the nei,L;iib<iurhood m the luistaidiiaii tube. It 
is import, mt to rut o,| the wound c,i\'it\' trom the n iso- 
pliarynx either b\- well scr.ipint,' down tin tube, so as to 
cause a cic.itrui.d atresia, or it the tymp.mic membrane is 
l.iiily well pieseived it ma\- be lelt in order by .idhesion to 
the inner t\in])anic wall to (.i)taiu a like result. .\ll the dee|) 
.-mlaics ol the attic and other pi, ices where the bone • ,it .ill 
soil are thorollL;hl^• curetted, .ind the w hole i.| thr b<iii\- ca\it v 
sw.ibbed with Lister's str<ini,,' tluid. 

rile me.it.d flap descril>ed on p ji(> is n v rediKcd to ,i 
skin tl.ip b\- disseciiiiL; nil ,is much o| ihi- eoniii'i ti\-e tis^ui- 
,ind 1 .11 lil,it,'e as pn-,sib'e coutmimiL; this ienio\Ml as l.ir into 

till lissiiesol thf.iUI e ,is ( ,111 lie dure w ll hoiil clli 1 1 >,|< Imif^ 

-'II the I, ilil.if^e 111 ;!.. .Miich.i. rills skin llip is now di.iwii 
b.ikw.iids, .nnl .ittac hid to tlu i.iw sui l.u e b\ twd or three 



220 



/fjxnnooh- OF i)isi:.\si:s of tiif. far 



mi 

111 I 



! ; ! ,< 



• I 



sutmrs ill -.lull ci way tlial, when the aiiriole is roplact'd, this 
skin tlap cinresiionds witli the lidU" that lias ])0(_'n cut in tlie 
niastnid l)iiiu\ The sntinvs slimild pass conii)let('ly tiu-ough 
tlie skin, so as to be removable from witliout. It is advisal)le 
to stretch tlie external oritice of the nieatns to insure ease in 
sul)si'quent dn-ssinj^'s. The wound is tiiially carefully dried. 
]iowdered with iodcjtorm. and packed with a strij) of anti- 
septic .i^'au/e titjlitly Ironi the bottom soaked in iodoform 
emulsion, and its tree md c.ir.ied thi-oui;h the external 
niratus. I he 110-,1-auricular wound i-, i losed by means of 
sutm-es and a suitable dr(N-,ini; applied. When closint,' the 
jiost-oral wound, it is well to commence the stitches with 
the middle one. but takiuL,' care that the anterior m,n>,nn 
is attached ratliei" hiLjhei- up than appeals to he necessary. 
r>\- so dom.L,'. one pieveuts ilic car lalhni:. which it is 
very ajU t<i do il the stitches are put in so that tln' two 
i'<lt;vs ap])ear to lie correctlv apjiroxiniated. It may be noted 
thai it i-. not Iu■ce■^^a^\• to put an\- poition o| the band,n,'e under 
the chill, a plan which adiN i,'rcatl\- to the comlort ol the 
patient diu.aL; the tiist twent\-|our hours. 

>ulKeiiuent drc'^Nin.irs (on^ist in pa( k/i',' a Ion;..; stri]> o| 
sterili/ed gau/e thioUi^'h the external meatus, so as to (■ntiielv 
lill the udund (a\it\-. I'he-e diessin,!..'-. should be cllan,^'e(l 
as <ilten as aii\- dis( li,iix;e shows through tlu' external dressing 
ol two 01 three l.iyels ot g.iu/e covered 1)V Cotton-Wooj. Tlu' 

uio^t ( omicit.ible method i,| keeping the liist ('1 ing on i- 
bi einplo\- the ^lgllre-o|-ei^r||t turb.in-wise. not going under the 
chin. l"or the subsi'quent dressings the shield shown on 
rig. f)^ is Nei^- con\-,.nu lit and light, being made ot vulciiiite. 
In 'he .ibove o|i,i,itinii there ,ire two d.iiigeis to be borile 
in mii.d : one i> th.it o| woimdmg the l.iteid sinus, the other 

tint o| mpiiiilL: the !,iei,il llel\-e, I hele Is also the possll)ility 
ot exposiii:,' the dmM m,it,.i ,,| the mi. Idle |o>->j ; juit it this 
last .a (id, 111 sh.aiid Icippeii. it 1-, (juite Ire,' tr,,m (l,iiig,'r. 
'be situ,itioii ,,1 ill, .iiiiium is ,oiist,int, .md it-, iel,iti,)nsiiip 

t" 'h,' I, a III 11, i\-,' 1, pi.Mtl, ,ill\ , o||-,t,iut. thoii-h the p,,sll|,iii 
"I the I, ill i.il sinus Is iiiiloi tun itel\- not ,0. ; li ■ LTeiua.d ,,111 
liguratioii o| till- skull i, l.iii,'el\ H'sponsibl,- lor tin . mvgul.ii it\-. 



i 



A. 















(yprn.rrinxs; 




221 


In 


tho 


pro 


"•ortionate 


\" 


long skulls tho 


sinus is situated more 


l^osU'rioiiv 


tlian 


in those in wiiicli tlie 1 


lead is relatively 


broad. 


It 


is in 


the 


atto 


■ tyi)e 


til 


at the middle t'( 
Facial Nerve. 


)ssa is apt lo be o 


peiied. 




Tlic 


f;ici, 


il nc 


■\-i\ w 


lii 


h. in its usu d 


course, lies just 


out of 



the diiiiid' /line in npcr.itions on the mastoid- -e\'eii the more 
e\tensi\-(' ones reipiiicil ,is a preliminar\- to l,il)\ liuthiiie opera- 
tions niaw ainl occ.isii in ill\' dms, come vr\'v tar torw.irds. 1 1 
is sii(l, indeed, to pass .ii>o\c the aditiN. cumim,' then close 




iir,. 'I'l. -\-ri.c \Ni I r mmiih }iiu ki i.m.msc, dm-ssinc- on tmc. 

.\rii\l. WOINII \lll;i< M.NsKilD Ol'l l;,> 1 IONS. 

down behind the posterior w.ill o| the extiTiial me.itus ,ind 
ma\' lie so l.ir extern. d t" this usu d ciaiise ,is to lie louud 
within^ iui h ot ilie --urt.ii e ot i he bon(\ In these occisp.n d 
\Mrl.i1ions the l.ici d neive must lie exposi d to cert, lie. di\as|iin 
it an operation h.is to he nndeitaken in such .i case. Ihiice 
the iie(Cssit\- th.it exists liir the close o!>st'rvation ot the 
jvitient li\- the .ma-^tlieiist . .ind his instant report of ,inv 
t\\ it( hiiu: o| the l.iee diirniL,' till- operati"!). N'ctinn ol the I.k i.d 

UelVe c.iUses nUe ^p.lsin o| the wiinle i>\ tlie i.ii ial TU'Wclcs on 

til it side, a sp.ism which i> never repe.ited III aiiv toriu diirm.i^ 
the oper.ition. It this sp.e-m comes earl\- in tlie operation, 

t he 1. 1 c i.d is dl\'lded ,llld -^iinllhl he 11 illlledl 1 tele seuc lied toi . 



ill 



! is 



m^ 



V (! 



r 



222 u.txnnooK oi- r)isi:.\si:s oi- rur. j-.ar 

'Ilk' nvvvv shduld then W carcluUy lifted out of its can.il as 
tiiat canal JMipciicd, tlu' gri'atcst jxissible care iK'inj,' taken that 
whilst SM haiidiiii.t,' the iieivi' the least i>(issi])le amount of 
trauniatisin !>.■ inflicted, and the oiHTation as was orii,'inally 
inteiuU'd should he conij)Ieted belore anv ste])s are taken 
towards reunituii,' the divided nerve. When the original 
operation has hei'ii completed, the dist d end of tlii' facial as 
It lies in the hone should he loll,, wed up until the nerve is 
exposed in its whole imra-osseous course. The ends are then 
easily hronght into ajiposition and mu>l he carefully attac lied 
to i.ne another 1)\- sutiu'es. and should the operator hwv a 
small decalcilied Ixiny tube the nerve ma\- be enclosed in one 
as lar as |)ossil)le before suturing. 

1 he distincti-'us to make between the section oj t' wviw 
and the scrapir.g or bruising (jt ,in exposed portion n ,t, are 
that when 'he nerve is onl\' pressed on or scraped, or otherwise 
sfimul.ited. but n<it cut, <<\\W a portion of the facial muscles will 
luit( h c<iimnonl\ the muscles ot thee\-elid , mil its neighbom'- 
hood, and they will twitch again it the nrnneuvre which jiro- 
duced the origin il twitch is ivpeateil ; whereas, as is st.ited 
beliiie, in the eveiit o| complete section one f,,'iiei-,d sp.isiu 
alone is noticed, .md (amiot be reproduced without the aid of 
a galvanic ciurent. 

Section oi tiie l.ici.d nerve should onlv occur when the 
nerve Is l\-ing in .m abnorm,d sUiiation, .md it seems tint U'l 
care is likely to pii,te(t that ,il)iiornMll\- |\ing nerve, iiiit 
with the IK 1 ve in its iiorm.d sUu.ition its di\-ision should never 
occur. 

Treatment of Divided Facial. - I'.e\nnd th.' nu'thod alluded 
fo pre\iousl\- (.1 imnu(li,itel\- sutmnig the duided nerve. 
\' hii h is niil\- p,,ssible where no p..rtii>a ol the nerve has 
been reiiiMVed, the next best iirocedure is to attaidi the 
iiiive ti' the hvpoi^lnss.d. I he h\-poglossal is (>xposed bv 
■"1 I- isioii ciMinieiiemg .It the anteiMi i)nider o| the steruo- 
m.etoid mu-iic, uIikIi is c.inied down sdtne j in- lies. Hv 
a c.uehil diss,', lien, (, Tie shmild be ,d)le to jnck up the I.k i.il 
iicivc lu^i as i. enters the p.uotid. It is th.ii ( ivtullv 

iollnwid ji.M k as l.ir as the .!.•. n. .-m isl, .i.I I, vi- ,..,...> M,... 



nrHR.tTioxs 



22^ 



is tlu'ii at liberty citlior to divide tlic nerve at this jxant, 
or tn dissect it (Hit by reinr.\ing the bmie so as to nljiaiii a 
rather longer i>()rti(ni of the nerve. The liyi>ot,'lor-sal is then 
lound (lossiiif,' the wound transversely at the lower border 
of the digastric muscle. This nerve is then divided, and the 
facial nerve attached to the proximal extremitv, the greatest 
care being used to injure the nerve as little as possible ; the 
transverse process of tlie second cervical verti'bra is a useiul 
guide to the situati<in of the hypoglossal. 

Fully six months is usually required for tlie nerve to <(>m- 
mence again ti> exercise its function, but massage to the tacial 
muscles should be connnenct'd inmiedi itely after section of 
the nerve, and this cominned with galvanism should be 
steaddy per>isted in until complete recovery is obtained. 
Ihe loss of muscular power to the tongue on that side will 
cause a considerable amount (j| inconvenience until the 
I'alient has lieconie accustoiiUMl to the .dtered condition. ,in(l 
will to a cert, tin ( tent interlere with speech, as well as ju'rhaps 
involve a certain amount of injur\ to the tongue by the ti^eth, 
but this will UKt be of very great duration, and will not be the 
source ot iiermaueut anno\Mnc e. 

The lateral sinus on ihc Kit side lies somewhat more 
anteriorl\- than on tlu riglit. but as a gener.d rule tlie vessel 
liis about ] in( h l)ehind the extern.d meatus. Shoukl it bi- 
exposed timing the o]h r,ition. re.isonable care will prevent 
injury, .md nn ill-ellect-, will ti.ll,,\v. 

Iiijmy ot the later,d suius is evidenced b\- an alarming 
rush ot dark blodd. llw ii.emonhage mu>t lie tem|>o! .iri!\' 
chei ked by the linger, and .. long strij) <if iudolmiu t;,iuze 
jnished up /;,/,. ccw the sinus wall ,.iid the :;roo\-e in which 
it lies, and .1 second strip of g,iu/e iiiM'itid in .1 >innlar way 
downw.inls. This |>acking may be removed .it the end of 
toity-i ight hours. 



ii 



Skin-Graf ting. 

shortening the jKii'id neces-,:ir\- fdi mre. 
skin gr.itting li,is been advocated. I he gr.ilt ma\ be .ijiplud 



With a view o 
r.ittini 

iniinedi I ti'l\- 111 



i.Ki i.l.a;, 



1 1.1 



t? 



\l Si 



It ' 
ft 



224 



ii.ixDHooK oi- Disi: isrs or the i'ar 



abst-nco of aiiv caustic antiseptic is assured bv free irrij;; ition 
witli sterile saline s(»luti()n. or the wound is reopened at a 
later date. A large Thiersch's graft is a|)i)lied covering the 
wiiole cavit\' as soon as the interior of tiie bony wound is 
covered with graiudation tissue, or smaller grafts may be 
ajiplic^l thniugh the external meatus to such ]>ortions of the 
ca\Mt\' as are easily accessible, or which seem most suitable. 

riie emi)lo\nient of skin gr.dts in certain cases, esi)eciallv 
in the up|)er classes, has great advantages, but a second 
operation is involved in the above-nientioiu'd method, at which 
numlirrs of ])eo|)le not unnatm.dly demur. Also, if the ear 
should ag.nn become the seat of suppur.ition, a condition in 
no w.i\' distinguishable fmin cholesteatoma is set uj). 

i'he after-treatment, if grafting is not emploved, consists 
in changin.g the dressings less and less frecjuentK' as the 
discharge lessens, being i).irticularly carefiU to plug tirmlv 
to the bott<im of the wound, and to fill it equilU' in all direc- 
tions, for unless this be d<ine graniilation tissue will form, 
and so diminish its size as to eventually comitletelv occlude 
the cavit\- In lact, cases do occur in which this tendencv to 
(■\cessi\-e gr.imilation-tissue formation is so exuber.int and 
persistent that, dcs|)ite ,dl elforts. the cavity is comjiletelv 
obliterated. For the lirst two wi :'ks it is absolutely necessary 
that ,dl thuds used lor inigating the operation cavity should 
ha\e strong germicidal and somewhat caustic powt>r. Two 



solnlions which 



lossess these properties are 5 pei" cent, solu- 



tions (il culinlic acid and ,',, per cent, of corrosivi' sublimate. 
It is strongly advis.dije to be.ir in niin<l th.it. •^honld septic 
changes be allowed to oci ni", the danger to which the jvitient 
is subjected is as gicat. il \\nX gre.iter. than it no opei.ition 
had bi'en perloMiied 

As .in altern,iti\'e method of treitment one ina\'. aftei' a 
iew jLickings, inseit ,1 rubber tube int" 1 he me.itus as l.irge 
as possil)le. and icK' on .dcohol instill, 1 ions to cnise a rajiid 
cicatriz.ition. I his. thoiiLrh oiten successlul. is apt at times 
to cause toil r.ipid t loMiie o| the i>.irts. and is ot somewhit 
donbtful v.ilue. 

Winn it is proj>os((i to gr.ni. it is weii liiit liie solutions 



'ilL.^. 



OP/f AM r/o.v.s" 



235 



used for irrigation of the cavity between tiie time of the first 
and second oj^erations should not for the last few days be 
of caustic strength, as they tend to liardeu the granulation 
tissue which is formed, and do not leave a suitable surface 
on which to graft. The grafts are taken from the inner 
surface of the thigh, and too much care cannot be exercised 
in rendering the surfaces from which they are taken aseinic, 
the least negk-ct of the most scrui)ulous precauticms being apt 
to lead to an increase of sujipuration in the cavity after the 
graft has been inserted, and to the death of the graft itse'f. 
The p.irt from which tJie graft is to be cut should l)e thoroughly 
washed with I'ther and soft soaj), or with i^ Jier soap, forty- 
eight hours before the operation, scrubbed with a nail-brush, 
sp(mged with a mixtuie of ethei and alcohol, and, nnally, 
an antisei)tic dressing carefully aiipliecl and kept in its place 
by a spica bandage. If the patient is one wlvw,. social 
position or habits of lite have pievented the regular use of 
baths, a second cleansing sinniar in all respects to the first 
should be carried out twenty-four hours before the operation, 
and a ln;sh dressing ap})lied. 

Ihe j)ost-aural wound is reopened, the dressing removed 
from the cavity, wliich is then well urigated with a sterilized 
saline solution, and curetted to remove all iiroliferating 
granulation tissue. It is then aga.in cleansed with saline 
solution, and packed with gauze well soaked in adrenalin 
in solution, with a little ]>ressure in order to check all bleeding 
by Hie time that the graft is cut and ready f(.r applica! 11. 
llie dressing from the thigh is removed, and the part I .m 
which the graft is to be cut sponged again with alcohol and 
ether. A sterilized bar of wood or iron is laid across the 
thigh parallel to and just below I'oupart's ligament, luid kei)t 
pressed lirinly down and held by an assistant. The operator 
then with his lett h.nid draws the skin of the thigh downwards, 
so as to render I lie surface tlat. The graft is now rut with a 
iieavy wide-bl.ided Thiersch's knife, and should l)e of suffi- 
cient size to line the whole cavity and obviate the necessity 
ot eniii|o\ing a second. A little saline soluticm droiiped upon 
the i.i^or ,111(1 the thigh as the graft is being cut assists in the 

15 



; (- 



22fi 



IIAXDIIOOK or DISEASES OE THE EAR 



111 



ease witli whicli the skin may be cut, and tends to prevent 
curling,' ol the ablated skin. Tlie graft is now transferred 
In a sliillow dish containing warm sterilized saline solution. 
A (htssing is ajiplied to the thigh by an assistant, the most 
((inifortable one being a jiiece of lint spread with aseptic f)int- 
ment. The ojHrator now exposes the mastoid wound, and, 
when all oozing is stayed, he proceeds to apj)ly the grift, 
wiiicli is takin up on a large section-lifter and applied over 
the bo]iy wound in such a way that its edges rest on the 
fleshy jiarts. above as well as in front and behuid, any folding 
of the graft which may have taken i)lace being i)romptly 
corrected. The graft is carefully worked down into the deei)er 
p.uts ol the wound by means of long needles fixed in handles, 
and is then i)ressed into its deeper recesses either by means 
of needles or bv instruments specially constructed for the 
purpose, any moisture whicii has accumulated beneath the 
graft being sucked out bv means of long glass ])ipettes, which 
are also useful in securing a cli>se ad.iptation of the graft to 
the walls of the cavit}'. 

After the graft has been ap'pliLcl as above, the wound is 
to be tiglitly jilugged with a strip of sterilized gauze, well 
ixnnieated with sterilized parolene, which is firmly pressed 
into the wound, thus keeping the graft in close ajiposition 
to the bone. The remains of the graft, which would other- 
wise lie outside the wound, are carefully turned forward over 
the gauze plug, so that the inrer aspect of the Ha]) not covered 
by the jnece of skin t.iken from the posterior meatus shall 
receive an c})ithelial covering. It may be necess;iry, how- 
ever, to apply a second small skin graft to this part. The 
wound is reclosed with sutures, and an antiseptic dressing 
a])plied. 

It ought to be borne in mind that during this grafting 
operation no strong antisejitics are used, since they diminish 
th( \ it ilitv of the graft. 

Till dressing may be changed on the second day — preferably 
on the third — the woimd irrigated with sterilized saline solu- 
finn (>r \vf*:ik b?>!';!ci{* ]oti<»!V :nid re-i)lut?L'''- d. (^ccasiouidlv 
the whole of the gralt comes away within the fust fortnight. 



11 ill 



Lau 



OPERA TIONS 



227 



The reason of this will be because— («) Too powerful anti- 
sei)tics were used previously to the operation ; (b) the graft 
was too tliick ; (c) a certain amount of fluid vas left beneath 
the graft, which prevented its adhesion. 

Besides the method of dealing with the external meatus 
which has been described, two other methods are worth con- 
sideration. The first is to remove the jiosterior half of the 
external meatus entirely. This rather shortens the opera- 
tion, and at the same time removes the ceruminous glands, 
which, if transplanted and removed from their natural support, 
may give rise to trouble by tilling up the operation cavity 
with a mass of cerumen. 

The second method of dealing with the external meatus is 
to divide it horizontally through the middle of its ]iosterior 
wall, and vertically at the juncticm of its posterior half with 
the auricle. When this procedure is adopted, great care 
must be taken to keep the meatal flaps pressed upwards and 
downwards until they shall have become attached in their new 
situations. 

The clinical results of the radical mastoid operation are 
extremely good, and in a large majority of cases complete 
and lasting cure is obtained. It is most rare for the hearing- 
power to be injured, but, on the contrary, it is more fre- 
quently markedly enchanced, whilst the improvement in the 
general health of the patient is obvious to the most casual 
observer. Occasionally, however, it is necessary to ojierate 
a second or even third time ; nothing except experience, aitiid 
by the greatest care, will i)revent these cases from cropping 
up now and then, and also the occurrence of post-auricular 
sinuses, due to the operation, should be prevented. 






The Mastoid Operation of Kuster, or Seml-Radicai Mastoid 

Operation. 

This operation, recently restored to a place in aural opera- 
tive surger\-, deserves to l)e noted, as it is one which is of 

-.1.. • .1 _i 

v.;;;:;- ;ii iiircc t i.i.-,sr-.-; ui t,a?,cb — \u., attic suppuration (either 

alter failure of, or instead of, the sirnjile iirocedure noted on 



h'i: 



( i 






I j 



22.S 



UAKDnooK or- i)isf'Asr:.s or riiF. far 



p. 162), and in those cases wlicre the tympanic nu'inbrnne is 
only (lesiroyed in its u]>pcr and jiostcrior part, wlierc the 
t3'ni])anuin is imt involved, and where there is no suspicion 
of labyrinthine supjiuration. It is also apjJii'able to ineatal 
sinuses with an intact t\ nipanic membrane. 

In this operation the posterior wall of the meatus is only 
cut awav suthcientlv to o]icn the antrum and aditus, but if 
the antium is large and exti'uds low down, tln' ojieration is 
converted into a complete or radical one. Should, however, 
the disease lie limited to the attic and aditus, and should the 
antrum ^"^ small or not diseased, then the operation is 
restrict! . so as to leave the membrane and os^icles hi ^itu, 
whilst the external wall of the attic is freely removed. Tlie 
wound is packed after thoroughlv cleansing the ]>arls as 
directed on ]>. 2Zo. the meatus l)eing merely divided length- 
wise at the u]>per and ]ioMti'rior part, '-o ;is to ])ush the 
edges welf into the bony cleft, and subsequent packing 
employed. 

After-Results of Operation. 

Where healing takes i)lace satisfactorily, whetlier t!i:.? iv 
due ti> antiseptic treatment or to grafting, liearing will be 
im]»rovcd in a large numbiT of cases. Hut where the hearing 
is already lost, as will be shown 1)\- tuning-fork tests, no relief 

;i be exjjerienced. 

If healing does not occur it mav be due either to some 
jiortion of the bonv wound refusing to lu .d, or to a contrac- 
tion 1)\' re.ison of fxces-iive formation of granulation tissue ; 
or sui)i)uration mav recur during after-treatment from care- 
lessness. Healing may best be obtained by the applicati-'U 
of a small skin-graft to the area still rebellious to antiseptic 
cicatrization, lixcessive granulation may be ke;)t down by 
the use of caustics, or, where necessary, of a curette. If the 
external orifice tends to contract, a largt indiarubber drainage- 
tube slundd be inserted, and onlv takt n out for ajiplications 
to the cavit\'. The use of alcohol in the form of drops in 
tiiese rei)eiiious cases is oilen oi extreme iieiii'iii, inii cases wiii 
occur which tax the patience and intjenuity of the surgeon to 



%La. 



Ori-RA TIONS 



229 



till- utnidst. Sed.itiw niiitimMits init\- avail wlifii astriiigrnts 
1 il. 

l'i)sl-i)|HTativt' ncunilgia, cliietlv in tlie course nt \\\c f^ivat 
auricular nerve, is snmeliiiies cnnii'iained of, and will yield 
t" i>rdinar\- anti-neuralgic tre.itinent, and to frictions with a 
mixture <■! chl-iroforiii, aconite, and belladonna liniments. 

The hearing-jH/wer after a mastoid operation will deiH'nd 
upon, in the hrst place, the condition of the nerve, and will 
1 irelx' be wor-e th.m 'vfore operation, and in a fair propor- 
tion ot castas i-, excei'iion dl\- good the improvement being 
III rki 1 1 he condiimn ol tlu' stipes and the ]u"esence or 
absence ot iMMnulati' 'i ti'^sue in the iti,'ion of tiie o\-,d window 
have a inalerial intluence upon the residual hearing. The 
stajies i..,iy Iv n moved uitii . dv.ml.'ge. jmivided the wound 
is thoroughly ^^cptic ; but a b, st" lelt in the niche without 
the rur;e wil' .dways gi\i- ..n indifferent re-ult. 



Operations on the Labvrinth. 

A flap is h>ruie(l in liie ioHowing w.iv : A scalpel is inserted 
into the meatus, with its edge directed forwanls and upwards 
in such a w ty that the edge ol the heel of the bl,nle lies be- 
tween the tragus and the coiunii -k ement of the helix, tlie rest 
of the edge being dii.ctt 1 betwe. a the juncti 11 of the anterior 
and superior walls of the meatus in which direction the 
nieatal wall is divideil d vn > the bone (see arrow in Fig. 67). 
As tlic knife is withdrawn, he incision is carried upwards, 
close to the hehx, until the u, ler border of the insertion 
of tlie concha to the head is reached ; it is then carried 
backwards and downwards with a bold sw(>ep, following 
much the same direction as is usual in a po t-aural opera- 
tion, but without brimming the lower part of the incision 
materially t .rward The ear and external meatus are then 
dissected out and turned downwards, being, as it were, un- 
rolled and laid on the tissues of the neck, l)elow the angle 
o* the jaw, and enclosed in 'erihzed antisept'c gauze, and 
;;eii.i ;:; j/';;;i r ;/'\ a .jI;; ;;. i iiis rrn_Uioci tn Cieaiiiig \Vitii liie 

ear iii l only permits an ex^ ■,;llcnt view of tlie parts, but enables 



m 



230 



HASDliOUK 01- DISEASHS 01- I HE UAH 



;rr 



u 




one in working to avoid any possible injury to the nieatal wall. 
At the same time, the auricle being absolutely removed from 
the field of operation, retractors are dispersed with ; also, as 
tile wound is deepened, far more light is availabl- in its 
deei)er parts than is obtainable bv other methods. An 
ordinary radical mastoid o])eration is performec', but the bone 
is cut away as much as possible in the ujiper and back part of 




IK;. 6j. Till". LINE Ol- AUTHOR S INCISION HMI'LOYlai IN Oin;RATIONS 

ON TIIK LAHYRIM1I. 

* * Ibc line of inrision, -the dottcl line tlir jiart nf the incision liiildcn 
liv the aiini k'. Ihi' knife is introilmod with tin' im1l;c jiointin^; iu 
till' (liic.tion sliown by tlic- arrow, and thf external meatus is 
divided in Us wliole leiigtli. 

the bony wound. The bony external semicircular canal is '--ell 
exposed to view. l-?y means of a small gouge the whole of 
its upi^er surface is cleared from the more porous bone immedi- 
atelv su])eiia( eiit. The uiijier surface of this external semi- 
circular canal is then removed by the gouge, a burr or chisel, 
until the membranous canal is opened ; and it might be well 

.\ . ,1 T , f il.! , -. I 1 . !-„ ,1 

,.\, inch. The canal is then followed ui^ along its anterior 



OPI-RATIOSS --'■ 

and pn.tniu; limbs, antuiudy until the iiurc.^e in its r..libre 
notitus the el,,se pn^xinulv -f Hu" anipuUa, ami i.ostennily 
until its slightlv fonvanl (Uiocti<.n indicates the near approach 
to the vestibule, l-r the canals are not reallv semicircular, 
but rather exceed thi^. The next step in the operation i. 
to obtai-i tree a.ces, to the vestibule. This i, done bv J-nung 
Nvith a burr or chisel ;' sc two openings as treelv a. po^Ml.le, 



I 




PiG, 68.— TiiF, coMPi.i;Tr.n radical mastotd on.K.vnns. 

ESC I-xtrrnal s.minrcular .anal; C, a !a.-e d.vy maMoul or i>rtm- 
,„a.t..i>l crll; 10 and FR, the oval an.l roun<l wi.i.low. { I lie 
post.r.or nieatal wall is not so completely cut away as for siip- 
]mrativc disoasiv) 

and It this does not make a large enough oiu-ning. further 
room may be obtained bv opening the posterior canal behni<l, 
and parallel to, the facial nerve. The opening into the vesti- 
bule is then enlarged in every direction by means ..f fine 
chisels (Fig. 70). The commencement ot the suiH'nor canal 
should be freelv opened, and its ampull.i scrape.l .nit. It 
is more dilficult to open the ampulhi of the posterior canal, 
which is silnate.l at a lower level. Tiic posterior and Mipeii-u- 



232 



iLiXDiiooK 01- nisL,is!:.s OF nil: i:.iR 






I 



■hi 



canals arc not interfered witli, but tlie anipulku are to be 
carefully curetted (Fig. 72). The next stage in the ojieration 
consists in treelv opening the foramen ovale bv abstracting the 
fo('t]>late of the stapes, so that no jliiids could be ntained 
in the (»pened vestibule, and enlarging the orifice as niucl 
a^1 pw^^ible. Tile wlmlc (»iierati<)n Ca'.itv i-i well cnictted. 
cleansed with a strong antiseptic solutinn, and commercial 



'J- 

■'i> 



[■ li 




IK,. ('I- /■',S(\/ .llul I SCp nil AN n HKIK AM) lOSll KlUK l.IMUS <l I 111 
1 XT I I<NA1. CANAL, Willi II A lO I I I 1 <i%\ I 1 1 1 T IM C ) 1 II 1 VI h I 1 1 I 1 I . 

fornialiile employed to wipe out the cavity oi the vestibuli', 
then well tilli'ii with oilv iodotdrm emulsi"n, and p.uked with 
sterih/til g.iuzc, the tiid ot wiiii ii is biiiUL;iit I'Ut t" tJic 
nif.itu^, and tiif ear iciil.Kcd. the greatest tare being taken 
to see that the helix loiiies ba( k into its origin. ii ]>iisitioii, 
Atter-treatment as for a radical mastoid operation. 

Alternative Labyrinthine Operation. 

Ii for .i:iV rr.isuli the iab\-|illth I'quiies cr|.eninLr. wlletlicr 
it !),■ fur pilij'd:,!-, nl ill\'e-tlgatl"ll 'H l"I tile lellel ol 



OPERATIONS 



'■^•'^ 



syiiiptoins duo to suppuration within it* cavities, in the cases 
wiiere tlieiv is reason to apprehend the presence of cerebellar 
abscess, the following method (Neumann) is valuable : A 
prelimiiuirv mastoid operation being completed, the bone is 
cut away still more until the posterior fossa is oj^uned ; then 
proceeding forwards, t!i.' posterior canal is reached and cut 
away, thus <>p(,ning tlie vestibule behind and below. 




FlC. 70. -1 111 COMrl.ITI !) Ol'lUAIKlN. 

/; I'.iwtl.- i.asMimtliM.UL;!! \.-.tiluilr (l) uii.l <.v.il window ; SA . ampulla 
■ ,,( suiV,,..r .,m;il; C. -.11, JM . bar ot bunc eouUmmig Luuil 
1 ^ui.il ; //i', f' .initn idluii'luni. 



Destruction or Ablation of the Cochlea. 

This opcratinii l<ir the relitt ol tiiuutus necessitates liie 
ii.iiil'le'c (icvtiuctinii ol till- orf^aii ot li.'.niiig. 

ihr pnliimii.uv -tep- ot thr .-pnatiMU will Uv found 
n,i...,tr<i uii p. j.;o ,/ ■cq. The ear-llap .IrsLMlnd on i'. J2<> 
>li.^uld I'c .ini'l-y.d Having then oi.tainrd a (omiilfte and 
lull view ot theiniddlr tar. by cutting aw.iy thr poMcrior 
u.ill a', lar as pM^Mble. so tiiat the oval and round windows 



ii> 



III 



It I 
It 



234 



iiAXDiiooK or ;;/,s7:j.s7:.s of riii-: ear 



arc clearly brought into view, and as much of the deeper 
portion of the inferior wall as is necessary to expose the lower 
part of the promontory, a straight gouge, not over ,'., inch 
witle, is taken, and whilst being rotated so as to descril)e a 
circle, with the mt)st jjroniinent part of the promontory as 
a centre, is continually struck sharjily with tht; hannner or 

liidrjr nf 'jofit 
((hifntniri^f'S 







\\ lii 

Is i| 



rill. 71. — shdwim; oi'i.NiNo oi- c()Ciii,i;a in roiw. 1 auykiniuix roMY. 

iii.ill.t. (",i!r i~. taken to keej) well aw,iy from the t.ui.d 
iuive, .mil I' .iM'id the posterior interi')r ( orner ot the inner 
w.ill <i| ill" iiodd'c e.ir, .is into tili■^ ,irea a kirger jugiiLir bulb 
til. in usii.il ni,i\' I'liijei t, ,ind its injury would, to s.iv the h' "st, 

( ( iHlplic.lli' III. it tcl s. 

.Mtcr ,1 -.iKut tiiiir the l"Mii' iiK ln>rd witliiu I lie goUL;e 

lilt-- |ici"lllrs sip.llMlnl, ,illd Is |(in(i\-(d ,llld tl.f (ixhle.l 



OI'ER.-ITIOSS 235 

is freely ..peiied. This free opening will extend into the 
vestibule, which Liter in the operation should l)e freely 
curetted. The contents of the cochlea are then scraped out, 
and a careful investigation with a small steel probe made to 



m» tf * MtLTXC" 




,.I(i, -J._DOlUiLi; CUKVI 1) LAHYKINTllINI-; CllO iri: I'Ult CLKANINC 

Tin: vi;sriuiLi-. and amitll.t:. 



ascertain that the outer or lower turn is as freely opened 
; ,d ,inpletely destroyed as the central and upi'erturn> Tlie 
modiolus is nuw seen as a sinall projection on the llonr ot 
tlie cochlea, and may l)e removeil by a simple blow of the 



cliisei 



This, however, (-pens up the sul)arachn<'id sjiace. and tl'M.ds 
tlie nound with cerebro-spin.d llmd, so the curettage ot the 
vestibule should hrst be undertaken. When tiie mo.liolus 
i:. removed, a plug of sterilized beeswax is crur^hed thnaigh 



,^ 



iUii 



» 1 » VT « t ^ _ 



„U; 7J.--UOOK .OR ASCKHTAIN.Nr. nKPTU O!.' ANTUUM, AN.) SO. r .lU.N 
l-lidlU l-OK TKAllNC. Si.MICIRCe.-AU (ANAIS. 

Ihr ,,pening until the lluw ce,.M'S, as this does u^t ,.lw,.Vs seem 
to occur without tliis inecautiou. 

A very large qu.intity of cerebr-.-spinal thud mav, ot couise. 
flow away without anv ill-effects. 

Ihe toile' of the wouml, as Well ,.s the ,,tte,-t rct.neut . 
.lie desciil)ed mule. M,i--toid ()).ei ilioiis. 






CHAPTER Mil 
MALIGNANT DISEASE OF THE EAR 

i\[ai.R.\.\n r disease lit tlif cxti'inal far may take the torin <■ 
indtiit ulcer. iiia!it,'nant warts, squami>us-rellt'(l carciiiniiia nr 
>arriiiiia. Malif,'nant diMease of tlie oxternal auditurv meatus 
takes the turm i)t squamous-celled carcinoma it adenn- 
sarcdina. 

ScjuaiiMUs-celled carcinoma may nriginate eitlier m 'he 
t(irm i)t an ulcer or a warty (.,'rn\vtli. rajiidly briMking duun. 
in either case the patients bein;.,' usually |)ast adult lil and 
presentinf,' themst'lves with a tteiid and usually saninu^ dis- 
charge trom the ear. whicii will be arc mupanied bv severe 
pain, though this is not alwavs very pronounced in tlu' earlier 
stages of the growth. Facial p.inilvsis will often be an early 
svmptom. On examining the extern, d nieatu-., in the ci e of 
carcinoni.i. il there is no obvious growth, a sinus with tonl 
edges may be seen in the wall ot the meatus, trom which the 
disc harge exu<les. An occasional early sign i- lixation ol the 
auricle. Hisjdt-, the age ot the patient and the .u^picious 
ai)i>earance of the growth, the ch.ir.icter of the dischaige, the 
rapid incidence of a he( tic appear.mce, and ti;e presence ot 
enlarged glands in the neck, will determine the diagno.sis, 
which ver\ rarel\- jrcsents anv great dilVu ulties. In the Liter 
stages the- rapid destru* tion or involvement of the surround- 
ing parts, the formation ot prolifenting gr.nmlations, thi' |uo- 
fuse otfeii ive sani'ius discharge, the aiipear.incc" ot the p,itieiit, 
the rapid t inai i.ition. piesciii -.o cle.ii- a jiicture i<i m.dign.inl 
dise.ise th.tt error is impossible. 

^hoiild the disease Ik: of the .ideno-( ,ut iuoui i tons vaiutv. 
originating in the tiisut'so' the extern, d me.itu^. it wdl r.ipidly 






.VALK^SASr DISEASE OF THE EAR 



237 



(, elude tho canal, with or without the lormalu.n of a malignant 
pulvi>-1)-ilhccnn a Icjetid discharge. 

At th ^ time removal of the growth should be attempted, 
all anatonucal landmarks l-ing disregarded m attemptmg to 
..btarn cmp'. e removal. If the middle ear l.e the seat o 
the disease, or if this ongin.aes m the surrounding l-one, it 
max be of a mvxo-sarcomatous nature, which occurs in early 
,h,idhood, ^arcomatous or car. lomatous, ihe temporal bone 
in .ither case beomimg rapidlv involved ; ami the condition 
nv.v l>e (.- winch resemble, that ol an earlv acute mastouhtis. 
thoi. h the age of the patient with cancerous disease is often 
1. er than that at which acute mast-iditi. is found ; yet a 
large number of mal .mant cases occur in earlv a<lult lite, ami 
at the same tune the absence of anv history of suppuration or 
,.f illness M.ggestmg mtlueiua, and the general condition of the 
patient together with a careful examination of the deepei 
rts of the meatu. will usually enable the surgeon to recog- 
nue'the serious disease which is present, and prevent him from 
making an error in diagnosis. It is but rarely that supi^ra- 
tive disease ol the middle ear is L allowed by malignant dise.ise 
The lustorv of a case <.f malignant disease will usually be that 
the ixiti. nt lias sulle-ed a consider.ible time from pam and a 
certam amount ol discnmf.rt m the mastoid bone and sur- 
rounding parts, that ,. more or le.. dillu.e swelling has made 
its appear.aice behind the ear, which has gra.luallv uicre.i.ed. 
twL-ethei uith the exi.tmce ot glandular infection. 

U IS hopelrss 1.. attempt tiie removal of malignant disease 
st.irting in the .Urper parts ot the temporal b-ne, so th.it 
,1., sur-eon's ellorts mast be direcl.d towards obi.unmg 
tutlian .:.ia. 



p 



iii 



CHAPTER XIV 

OTOSCLEROSIS 

OroscLEKfisis. ]\kv tlic adhesive catanli, is a progressive 
suUinllainiuatniA altectidii. Its etinlngy at tlie ])reseiit time 
is ii')l cleaiK- deteniiined. but in a very large number of 
instances at least it is cunnnnitant to and part of a general 
sclerosis of the submucous tissues of the whole resinratory 
tract, of which the Eustachian tube and middle ear are 
diverticula. This ])athological ccndition is frecjuently in- 
fluenced l)y, or is dependent on, hereditary syiihilis. while 
heredity itself, ap.irt from the sjiecific taint, exercises a baneful 
intluence upon cases of this de:>cription. The sclerotic condi- 
tion alluded to connnenccs at the oritke of the respiratory 
tract— that is to say, at the anterior nares— and on examina- 
tion of the nasal chambers by anterior riiinoscopy the mucosa 
]>resents ajipe.ir.mces characteristic of rhinitis sicca. The 
condition extends into the nasopharynx and down the pos- 
terior w,dl of the oid-i)lia'ynx, and is said to extend as far as 
the submucous tissue of the finest ramitiiations of the bronchi. 
At \'\v<l sight the nose mav 1h' described as looking healthv, 
but ( lo>er inspection siious the mucous membrane abnormally 
nnl and dry, while the patients r.irely, if ever, suffer from 
nasal catarrh, or require to use a handkerchief. In mixed 
cases v.irioiis forms of n.isal obstruction are found, as in 
adhesive otitis medi.i Atrophic rhinitis and atrophic naso- 
ph.iiyngitis are frequt'iith' associated with deatm-ss caused by 
otosclerosis, in the e.ir itself tlie iwrliest condition known is 
mu( o-|H"riostitis of the inner w.dl of the tympanum, which 
m.i\' be recognized by the i)reseii( c of a pinkisli blu-.h or retlex 
in the region of the promontory or oval window, and seen 



OTOSCLr.UOSIS 



230 



through tho untliickcned tympanic membrane Mund tlic 
handle ol the malleus, higher or lower according to circum- 
stances. This periostitis may occur without known cause 
or may loll.-w an acute otitis media (Plate IV.. Figs. 10 

an<l ii). 

The pathological observations on record, from which we are 
able to arrive at a knowledge of the morbid clunges which 
occur during the progress of the disease, mostly deal with 
cases in which the disease has already attained some degree 
of severity. They show two distinct changes, <me class being 
the development" of patches of osteojx.rosis or rarefaction, 
wliich are found in various parts of the labvriiithine capsule- 
viz., in the promontorv. in the neighbourhood of the fenestr;K, 
and in the modiolus" of the cochlea. The other scries of 
changes c<msist in the formation of osteophytes in the environ- 
ment of the oval window, both mtratymiianic and intra- 
labyrinthine, the intratvmpanic osteophytes causing ti.xation 
of the sta])es, while tlie intrahibyrinthine osteophytes will 
directlv affect the intralabyrinthine space, and thus inatenally 
interfere with the auditory function. Besides this, ossiticati..n 
of the annular ligament around the footplate of the stapes 
takes place m the later pathological state. This is followed 
or acc.mipanied bv atrophy of the organ of Corti. 

In advanced stages of the disease, the labyrintiiine tluids 
diminish in quantity, and finally become jiractically n<.n- 
oxistent, though it is doubtful whether this condition is one 
entirely restrict( d to this disease, or d.-es not also occur in 
severe nerve-dealness due to arterio-sclerosis. 



The disease i' 



)uud 



even 



more 
fema! 



in early childhood, but .ippears 
trequently in young adult life, esivcially in an;emic 



Sv.MrTO.MS.— The onset of the disease is i:sually 
lual, but mav be c(.mparatively rapid. It may steadily 



('OURSE AND 



gnu 

])rogress or may 



be intermittent, and, again, may remain 
.1 of years, this period of rest In'ing 



stationary for a long i)erio(. 

usually followed by a sudden increase in deatness. 



No k 



nown 



cauM- ,ii)iHars to influence its i^rogress 



When the dise.ise 



oc< ins in I 



iuldun, It Is frequently accompanied by the piTMiic 



fit 



mn 



\\i 'li 



i 





if. 



I is' 



240 



UAXiuiooK or /)/svr.i.s7:.s- of the ear 



){ adenoid vefrotations in tlic naso-pliaiynx. 



an( 



1 it is due I' 



if otosclerosis that in a considerable 

for ileaf- 



tliis early condition < 

number of cases the removal of adenoid vegetations for deaf- 
ness is not followed by any imjirovement in hearing. The 
disease is sometimes unilateral at its conunenci'inent, but 
more usually bilateral, and it rarely remains one-sided tor any 
length oi time. 

1 he chief symptom is deafness, tending t<> increase, and 
r(>m;irkably uninfluenced bv intlation o| the middle ear. 
Tinnitus usually is an early syniptom, and may be complained 
of before deafness is noticed It increases in severity with 
the progress of the disease, and becomes an intolerable annoy- 
ance and a source of grave discomfort to the ]iatient. mere 
so. in fact, than is connnou in any other torm of middle-ear 
disease. It naturally inthiences most those ])atients whose 
habits ot life or temi)erament render tlum more liabU' to 
nervous di-turbance. As distinguished from the noises com- 
plained ot in adhesive disease ot the middle ear and other 
external and nnddle-ear disorders, patients sulfering from 
otosclerosis frequently refer them to the \\vm\ rather th.an to 
the ear. 

As subsidiary symptoms, a feeling of dulness. or occasional 
]iain and aching in the ear, may be complained of, especially 
in the earlier stages. 

r.itients sulfering with non-suppurative middle-ear trouble, 
even though it be slight, will occasionally coni]ilain ot the 
m<ist .igoii , ing \y,\. n the mastoid. 'I'his i)ain will not 
onl\- be compl. lined ot, but may apparently be elicited by 
])rcssme, and tiie jiatients themselves will beg for operative 
relict ; but in such cases a compliant e with their request is 
imsmg; .d and useU'ss, only s.rving to tix more lirmly in their 
minds the fact th.it thev are sulh ring irom .1 discise ot the 
bone, tile lines of treatment which must \v adopted in such 
cases being couuter-irritatioii, cspcci.d'y at some slight dis- 
tance from the jKirt as. for inst.ince. the nape ot the neck 

the administr.itioii ol v.ileri.in .iiid tonics, iie.dthv living, 

and. if necessa.ry, highlrequeucy treatment. And as it is 
possibly an intr.icranial neuralgia of a branch of the litth 



[1T^ 



nerve, injectioii!; 



oroscLiiiiosis -; 

)f alcohol into the Gasseriau giugliou mig 



ht 



like that of otlier middle-ear diseases, is more 



be tried. 

Deafness, 

noticeable at hrst in general conversation, but musical sounds 
are not usually jicrverted. Paracusis Willisii is a more frequent 
symptom than in adhesive catarrh, being due to the freiiueiicy 
with which the stapes is hxed. Finally a form of Meniere's 
disease is found at times as a complication. 

Tiiniii'^-Fork Tcsls.— In primary disease of the labyrinthine 
capsule, with the presence of rarefying osteitis, Rinne is 
negative, with increased bone-conduction, though diminished 
b<me-conduction may be present (Proportional Test o and'f)- 
Air-conduction will be diminished in all cases. If new bone 
should be thrown out within the cochlea, or if the disease Ijc 
complicated by secondary internal ear lesions, bone-conduction 
will be diminished. It is well to know that Rinne's test, 
wiiich is negative in this disease, may be either total or p.irtial. 
By total is meant that, if a tuning-fork of a pitch below CV as 
well as a fork of higher pitch, is employed, tae result will be 
negative in Ix-th cases ; but if it is partial, the higher-pitched 
tuning-fork will give a positive result. Gelle's test is valuc.ole 
in demonstrating the fixation of the stapes— that is to say, 
if Rinne's test is negative up to and including C^ and Gelle's 
is also negative, then the stapes is ankylosed. If Rinne's is 
negative below C and positive above, Gelle's test again 
derides the question as to whether the stapes is ankylosed or 
not. Air-conduction in advanced cases to all the lower forks 
is lost— /.e., those of sixteen, thirty-two, and sixty-four 
vibrations per second— the lower tone limit ascending with 
the progress of the disease. 

The condition of the membrana tympani in uncomplicated 
cases is markedly different from the condition observed in 
adhesive catarrh. There is little, if any, retraction of the 
membrane, which is more translucent than normal, the sub- 
jacent structures and contents of the cavum t>'mpani being 
frequently distinguishable to a greater or less extent, and at 
the earlier stages, as previously noted, there is occasionally a 
pinkish blush over tl-.e promontory. When, however, otoscler- 

10 



m 



ff!, 



:\\ 



tp n\'- 



242 HANDBOOK OF DISEASES OF THE F.AR 

osis is complicated witli adhesive catarrh, the membrane may 
present any apjiearance between the two extremes. The 
external meatus is often singularly devoid of cerumen, pale in 
appearance, with a tendency to exhibit a polished surface, and 
not infrequently it ai>pears rather larger in calibre than normal. 
This is due to an extension of the disease to the subepithelial 
tissues of the external meatus. Fixation of the handle of the 
malleus is only found in cases of otosclerosis when complicated 
with chronic catarrhal otitis media. 

The fact has already been stated that, in a large number 
of cases of otosclerosis, the nasal passages are unusually free, 
and present the signs of rhinitis sicca ; however, where this 
condition of the nose does not exist, and where there is a 
certain amount of nasal obstruction, tiie same patency of the 
Eustachian tubes is prest .it. This fact is of great diagnostic 
value. The tubes are abnormally free ; on inflation with a 
catheter or with Politzer's bag, the air is heard to rush into 
the middle ear with a large stream and witlujut any hindrance, 
also rarely with any relief of the deafness ; if the disease is of 
any duration, patients not infrequently state that they only 
hear, but do not feel, the air entering the cavum tympani. 

Prognosis. — ^I'his is very unfavourable. In a certain 
number of cases the morbid processes remain stationary for 
a long period of time, though the general tendency of the 
disorder is to become markedly worse ; careful treatment will 
no doubt enable the surgeon in a large number of instances to 
oljtain a cert.'iin amount of relief, or, at least, to retard the 
inarch of tlu- disease. 

Treatmknt. — First, with regard to the use of the Eustachian 
catheter and inflation in uncomplicated cases. This method 
of treatment will not only be unattended by any benefit, but 
occasionally appeal's to be followed by a temporary increase 
of deafness. When, however, the case is one of mi.xed oto- 
sclerosis and adhesive otitis media, the use of the catheter 
may be productive of a slight imi)rovement. 

The use of injections of various sorts is occasionally pro- 
ductive of good. Those most to be reconimenfleil are : 
Odoui .-ss paraliui ; i per cent, iodine in the same oii ; solu- 



ifSdtikimmn 



()T()SCLi:i^'()SIS 



34 ^ 



tinns of iodide <.[ pnf i-,siuni, 5 K'niins t^ tin.' nuiuc. llu' tliiiil 
i.iniment (viJc Ai)i)cndix .]>S) is tlic iim^t valu,il.l<> ut all. 
Tiu-se drops >h..iild bo intnKJu.vd int.. tlu- catlKt.r and blown 
into the middle car thii. • a week, orollemr. for several v 'eks 

(about six). 

Of other local measures, oto-nias^af^e is .dways t.. be I'rae- 
tised, unless alter the tirst applieation it is attended 1>\ a 
diminution in the hearing-power. It should b, employed 
daily, commencing with a [)eriod of about half a mmiite, which 
may be gradually increased to throe minutes, per diem. 

Of the two factors m i)neumo-n>assage, rai>idity of the 
vibrations and the strength (.f the i)ull. the latter is the less 
important. A light pull should bo employed, which nie.ins 
that the stroke of the inston i^ ^hort, but a high number of 
revolutions per second made u>c ot. 

The administration of internal remedies is worthy of trial 
even in pure cases of otosclerosis. If the c.ise, however, is 
one in which this disease is combined with adhesive otitis 
media (non-suppurative), oto-massage is likely to increase the 
good effects derived from tiiese remedies. Good may result 
from the administration of phosphorus. This should be 
administered with caution and in an oily solution (,'0 P^"'" ^"^'nt. 
in oil or mistura amygdahe), and be given three times a day 
after food, commencing with 10 minims, and gradually in- 
creasing the dose to 45 minims. If. however, stomachic dis- 
turbances are produced, the drug should 1x- given in keratin 
or glutin capsules. Besides this, one has the following 
remedies. Strychnia in full doses. Iodide of potassium, which 
should be administered in doses of ;, to 5 grains in J pint f)f hot 
water directly after meals. In ana'mic cases the syrup of the 
iodide of iron may be substituted for the i)t)tassium salt witii 
advantage. When mercury is administered, as it always 
should be if there is the least suspicion of inherited syphilis, 
it may be given as the perchloride or biniodide — the latter in 
the form of a pill, the former in combination with cinchona 
(vide Appendix). In the latter prescription it will be found 
that the two may be combined without any doi)osit l>eing 
formed. 



MICROCOPY RESOLUTION TEST CHART 

ANSI and ISO TEST CHART No 2 



1.0 



I.I 



*^ iM 111112.2 



li 



i:. 



Hill 2.0 



1.8 



1.25 



'•4 III 1.6 



^ APPLIED IIVMGE 



11 



244 



tr.ixniiooK OF i)[si:Asns oi- riii: i:ar 



li 

I' 



OrALCiiA. — On p. J7 we liavo already reviewed to a large 
extent the cair v's i)f otalgia, and where this has been referred 
to under the dis<'ases in which oral pain forms part, the treat- 
ment has lo a large extent ')een considered. But occasionally 
patients come complaini,;^- only of ear pain, a real neuralgia 
of the great auricular or of the posterior aiu'icular branch of 
the facial. This iniin, when unassociated with other neuralgias 
often comes, as I have said, under the hands of th(> specialist. 
It is an extremely dirikndt matter to effect a cure, but as we 
have stated elsewhere (p. 240), under no conditions what- 
ever should the surgeon be temjited to operate on the mastoid, 
but he should, if i)ossil)le, find out the exact si)ot at which 
the nerve courses cover the posterior edge of the mastoid 
jirocess. This is comj)aratively easily done during an attack 
ol pain, wiien bv means of one's finger-nail the exact si)ot is 
easilv l<icated. This having Iven marked. 10 to 15 minims of 
al)solute alcohol should be injected into the nerve, or as nearly 
as one can arrive at it. The beneficial effect of this treatment 
is extremely marked, jirovided the injection is made with the 
greatest care as t() direction. 

()i'i;k.\tivk Thi:.\tme.n"t or Tinnitus. — Mobilization of the 
stapes, trephining of the promontory, excision of the tymp:<nic 
membrane and ossicles, and the radical mastoid opera.tion, 
havt' all h.id their .idvocites, as has also the extraction of the 
stai>es. UntortunateK', the results of none of these ojierations 
justify their being reconunended for adoption. Hut when the 
tinnitus is reillv distressing, .iblation of the cochlea is quite 
justihable. and m,i\- prove successful — i.e.. wiien the tiumtus 
is aural .Mul not central. 



11^1 



n i' 



("HAPTKR XV 
DISEASES OF THE INTERNAL EAR 

General Therapeutics of Internal Ear Diseases 
(Non-Suppurative). 

Physiological Rest. — Tlie advantages which can be deiivcd 
tnnii (■(ini|)Ictc plu'sidlogical rest in cases <>; earU' deainess, 
especially when there is reasim to believe that tlie labyiiuth 
is already slightlv affected, are nut to be neglected. It sliMuld, 
indeed, alnmst be Cdiisidered as part of the routine treatment 
of most cases of deafness. Especially is it vauiable in mild 
oi" early cases. 

We ])ro|)ose several means of obtaining this ph\siologic;d 
rest. No doubt the best means to employ is to send one's 
patient to some quiet localit\', either to some fishing village 
on the coast, esiH'cially where the shore is sand\\ such as the 
East Coast, or to some secluded place, well wooded, where the 
patient can be away from all sounds, especiallv those ol the 
human voice and the rumble and turmoil of traflic. 

Where this is not to be obtained, one ear can be occluded 
largely during the dav on alternate da\-s it both ears are 
atteited. and Ixith must be ocdudeil .\t night b\- means ot 
plugs inserted in the ear, either making use o| the rubber 
sound deadener, oi <i| ^iiooters' wax or some similar iirep.ir.i- 
tion, 1 here is no doula th.it jurt o| the good elte( Is usually 
observed in p.itients who h.ive speni souw weeks in moiui- 
tainous districts owe p.ii t ol then impio\-emeiit |o the .d>seiiee 
o| noises in these regions. I'.irtii ulai l\- shouM the u^e ot the 
telephone be piolublted ill all ( .ises ot e.ill\' de.itiK'ss ot the 
middle ,ind internal e.ir. as the coneenti.ition ol sound and 
the I one eiitration nei'essai\' tor the receiving ot messages can 






IIP 



246 



HANDBOOK OF DISEASES OF THE EAR 



have no other but a deleterious eftect. It --eems also probable 
that frequent nose-blowing, by acting, as it were, as a chronic 
concussion to the lab^'rinth, is also ;i thing to ])e avoided, 
especially if there is any rigidity of the tympanic nienibnine 
and imniobilitv of the malleus. 



I J 



)■:! 



lis; 




Injuries to the Internal Ear and Auditory Nerve. 

Dinrt injiu'v ti> the internal ear can (inl\- arise trom long 
and hne articles being tiuust through the drum, and chancing 
til ]\iss thnnigh it in such a direction that it drives inwards 
t\k- ]ilate of the stajies, and penetrates into the vestibule. 
One such case is, indeed, upon record. The symptoms would 
be jiain, severe and prolonged vertigo, with })robably dimin- 
ished hearing, and unless the instnnnent w.is absoluteh' clean, 
these wouU. Ik! tollowcd by the symptoms of suppurative 
labyrinthitis Indirrct traumatic elfects are concussion of 
the hd)yrinth, and the p.issige of the line ot Iracture in 
fracture of the cranial base through the labyrinth. 

Concussion of the labvrinth mav be gr.ulually i>roduced or 
suddenly. In the lormer instance it will be by tiie effect of 
olteutimes repeated loud and more or le-^s sudden noise, as 
in battue shooting with nitm ]iowders ; m artillerv practice, 
chietb' with mai'hine or quick-liring guns ; or as is found in 
certain occupations, as l«iiler-makers and rivi'ters. Nor is it 
certain that frecpient and vigorous self-iutlation of a rigid 
tym])an\im will not jiroduce a similar result. In ■ ae latter 
coiuus>ion ol the brain ma\' be accotuiMuied by concussion 
ol tile labxa inth, or a blow over the e-U' ma\' h,ive a like ellect, 
with or without injurv to the tymj>aiiic membnme. 

S^■Ml'T(>MS. 1 he le.ist severe cases oi sudden concussion 
are jojlowed li\- a constant and iisutllv liermauent tmmtus, 
whilst to tlie more se\'ere will be addt'd de.ilness. 

In the (.ises oi gradii.d com ussion timutus ,ind dcilntss, or 
dcafne'-s with little timiitus. are complained ol. On testing 
tliese j'.itieMts, •>]]'■ tinds Kuuie ■' "r Knme < in the majority 
(»l cases, and wliispeied words ,iie lelativi '■, well he.ird in the 
mild cases, and in bojler makers |i,ir.ii usis Willisii is noticed. 



\\ I, 



1 1,. 



ii... 



..It ,.i 



,!.. .1..,..^ 



DISEASES OF THE INTERNAL EAR 



247 



variably noted, but is not always i^ermanent. A recovery 
in some instances must be attributed to the deatness being 
produced by the concussion, and not by direct injury to the 
cochlea or auditory nerve, and ]M-ol)ably in these cases the 
line of fracture will be visible in the external meatus. 

In those cases where the line of fracture passes through the 
cochlea deafness is immediate and complete. Vertigo is not 
often noted, as the condition of the patient does not permit 
of its discovery ; indeed, it is often that the deafness is only 
discovered during convalescence. Tinnitus is loud and very 
distressing. The patient (<lten has no aerial percei)tion ol 
tunhig-fork sounds, but C^ to C^ are those last preserved. 

The Prognosis in all these lesions is l)ad. 

Tkeatment is not satisfactory in concussion or injury until 
alter the acute inflammatory reaction has passed. Liq. 
bydrarg. perchloridi is the most useful drug. In what one 
may term the chronic forms of concussion reliance must be 
placed on strychnine or iodide of potash. 



Diseases of the Internal Ear. 

The internal ear consists of the membranous labyrinth, the 
cochlea, vestibule, and semicircular canals, which receive the 
terminations of the luditorv nerve ; in diseases ot the internal 
car are included those of the auditory nerve itself. The 
auditory impressions are received by the cochlea, while the 
semicircular canals are l.irgely concerned in the maintenance 
of equilibrium. We detect disease ()f the cochlea, as distin- 
guished fn>m dise.ises which jirevent ;■ und-waves trom reach- 
ing aud from stimulating the nei ve-endings of that part of the 
auditory nerve which •-upiilies lln cochlea, bv 'iieans of the 
vaiiiius sound-testing iuve-^tig.itii -ns. These hive already 
been described in the chapter on I'Lxamination of the Ear. 
The move important diagnostic tests tor internil e.ir dealness 
are, wiien the he,trini,'-i>ower tor speech is gre.itly reduceil : In 
e,irl\- ( ases material diminution or d mpiete absence ot bone- 
conductiiin I'M Puhl/er's .iciaimeter ni- the watch ; loss ot high 
toiK's. as slmun l'\' (laltim's whistle ; diminution <il I'r loss of 
Imne-cuin' 11 tion tor t\ming-torks. especi.ilU' thoM- m| IuljIi 



If! 



24S 



H.iXDBOOK or DISE.lSnS OF THE EAR 






pilcli ; Riii!U''s test is iKisitive, hut at tlio same time there 
is a sliiirteiUHl ]>erceiitiiin lor the tunes of tlie tuiiing-tork, 
and it the deatness is one-sided the fork in Weber's test 
is referred to tlie sound side. The ear is easily fatigued by 
testing, and hearing is worse in a noise, and at times bettor 
in \]\v oiH'H air in quiet places than indoors. The Eustachian 
tube will be i),itent, inllatioji of the middle ear will give no 
imjjrovi'mi'nt, and there may be no pathological changes in 
the middle vay. But the dilticulty of demonstrating conclu- 
sively a case to \k- one of intern d-"ar deafness is mateiially 
lesMiicd by negative evidence of middle-ear trouble. In- 
stances of nerve lesions occur which show h\-ptM'acoustii;a of 
bone-conduction. 

Diseases whi(di .affect the internal ear art' either primary 
or second. iry, the former being much the more mre They 
may C(jnsist in luemorrhages and in primary intlanunations ; 
whilst ;is secondly affections m.iy bi' taken traumatism in 
all its forms, and the effects of gener.d disiMses. sucii as 
syphilis, rlieumati'-m, ,gout, mal.iria. leucocyth:emia, etc. 
r>ut ot all the causes acting on the intern il ear, the most pro- 
htic .ire diseases of the middle t'ar, together with otosclerosis, 
which, although usii.dly ]ilaced fiu' convenience amongst the 
discises o| ilu' middle ear, affects at least e(iuall\- the internal 
<'ai . <'ert,iin toxie agents distinctly afft'ct the auditory nerve, 
SU( h as (juinine. the s.dicylates. opium, tobacco, and alcohol. 
i he specitii lex'ers, es))eei.ill\- lyphoid lever, mump--, iutluen/a, 
diphtheri.i. and cerebrci-spin.il nieniiiL'itis. ma\- be the can>e of 
■.\n\\v l.iliyrintliine changes, ciu^ini;- sudden .md pevm.inent 
d<Mfness. 

H.yperacousis Nervosa, i l\-p<'racou-i-. i-. iNu.dh- lomul (as 
ot,d,L;i,i) in leniales. and is rinK' noiiced. e.vcept when tlk're is 
some vlight atle(tiiin ol the .mdilorv,- nerve. It is usually 
int( use sounds w Iik li c.iusi' tjir p.iintui inipressinn. as well as 
SMinids (.1 I 111.;! I |iiich. \-et ,!n\ loud noi^c or sound will produce 
l!le s.inie ellri! il re-pc ct i\-(^ ol pittll. It is Vel\- lale. how- 
eN'er. to iiiid h\|ier.icoiisis as a sol\t,ii\- s\-ni|itom, but it is 
Usii,ill\- .!( I oin|i,inied by other manllesl.itions of a gener.d 

^::-- .■■•:::; ^ ■■: :;;; ;;;;m)U> bystc:::, a;i:i \:-\ l^iiS TCa^o;; ;;h^SC 



i.i.e 



< fc i ^ a 



I 



DISEASES OF THE IXTERWAL EAR 



249 



cases lie, for llie most \x\Yt. in tlie ]MMvince of the general 
])hysician or neurologist. 

The}' are extremely ditticult to handle, but while the general 
treatment suitable to the general eondition is employed, 
hyoscyamin will be found an extremely valuabK' drug for the 
relief of the sj)eeial symptom ; so also will valerian in large 
doses. 

Syphilis of the Internal Ear. —Acquired s\philis compara- 
tively rarely affects the organ of iiearing, but ma\- do so both 
in the secondarj' and tertiary stages. In the former there i^ a 
general hj'per.emia of the mucous membranes, which will 
invariably rajiidlv \'ield to treatment, and the deafness soou 
l)ass away, and requires no treatment directed towards the 
internal ear itself. In the tertiar\' stage, the acquireil disease 
will cause a mixed otosclerosis and lab\'rinihiti,^ with severe 
deafness and Meniere's symi)toms. 

Hereditary svphihs, also, is a frc(juent cause of internal- 
ear distnise. Here the period ot onset is in earlv adult life, 
usually shortly after, or e\'en during the ])rogress of, .an 
attack ol interstitial keratitis, and it may be that the pati(mt 
is even at that time being treated with antisvphilitic remedies. 
The progress ot the disease is one of extreme r,ii>idity, being 
biiatend and very intractable. Sometimes at the end ot a 
week, or even less, the patient is absolutely deaf. Our treat- 
ment must in consequence 1h> (>qvi,dl\- vigorous, and while 
mercurv should not be discontinued, iodide of potash must 
be given, and is best adniinisteied in 5-grain doses in hot 
water alter meals. Hesides these '-.pecitic rianedii's, pilo- 
caiiiine should be em|)lo\-ed ; nor should this lie delaxed to 
observe the result ol oui' ^ihei' treatment, it shoulil be 
administered in the form o| h\|)0(iermii' injections, com- 
mencing with ,,'„ grain injected under the skin ovei' the 
m.istojd ])rocess on eitlu'r side on .ilteiinte da\s iuc reasing 
Ihe dose r,i|iidl\' \ii) to i gi.iin, which should be considei'ed 
the Ingest dose homwliich luntlit o likrK' to l)e- diiivid. 
On ,,ccount ot the proiuse ]ier--pir ition wliii h is set up by 
this (IruLT- the p.ilieiit should be coiiliin'd to the house during 



I i 



t I V I I I I I I V 



p 



il 



I ' 



III 



M 'ia 



II 111 




250 



HANDBOOK OF DISEASES OF THE EAR 



and bark sludild be combined with the antisyphilitic drugs. 
Wlien pilocarpine treatment is not of anv btMiefit at the ex- 
piration ot three weeks, it should be discontinued ; otherwise 
it may be persisted in as long as improvement is noticed. 
Strychnine, the dose of whicli should be rapidly increased, 
should be tried if other drugs fail. The steady increase of 
the strengtli of the dose will usuallv enable the ))atient to 
acquire a tolerance for the drug, which may be inert', ised to 
12 minims of the liq. strych. thrice daily. P>at wha.tever 
treatment is adopted, it must be recogni/ed th.it the great 
majority of cases will not show .mv improvement in acquired 
tertiary disease of the labyrinth. Iodoform (in pills of 
3 grains) will sometimes succeed where iodides fail, and the 
same api)lies to the more recent organic iodine compounds. 
Salv.irsan is not to be recommended for aural cases, as its 
local effect is often most injurious. 

Gout. — Gouty disturbances of the intern.il ear are more fre- 
quently connected with subjective n<iises than with deafness, 
imless it is combined with chronic non ^upjiurative disease, 
and it may then be, and frequeucly is, accomi)anied by severe 
attacks of vertigo, which are, though partly due to the auditory 
trouble, accentuated bv the general dyscrasia. In considering 
anj' particular case, one must give due weight to any organic 
disturbances present, such as a large and flabby heart. But. 
while giving due attention to the gastric or circulatory dis- 
turbrinces, it will be desirable at the same time to employ 
such remedies as will lessen the aural trouble. These will 
consist in '-ounter-irritation behind the ear, either by the 
action of Ijlisters or rubefai'ients. If the latter are cm])loycd, 
the skin should be made tender, but vesication avoided ; 
whilst the internal atlministration of antilithics together 
with alk.dine nose-w.ishes should be ordered, and the naso- 
ph.irynx regul.irly kept painted with .Maiidl's solution (see 
Apiiendix), 

Anaemia. A deficient supplv oi nxygen in the blood causes 
frequently a diminution in the functional activity of the 
cochlea, in connnon with the like eifect experi<'nced by the 
otiier organs of tiu' body, and witii this an.emic condition of 



■Mki 



DISEASES OF THE IXTERNAL EAR 



2SI 



the labyrinth is closely associated those forms of functional 
or hystcricid deafness. It is, however, necessary in anaemic 
cases to be particularly careful as to how nnich direct treat- 
ment is adopted towards the auditory nerve. In these cases 
the tuning-fork tests, which show most erratic results often 
witli loss of hearing-power for certain tones, will convince one 
immediately that the disease is of neurotic origin, the j'atient 
being ; ble to hear a certain amount of conversation, especially 
if the questions asked are relevant and in a l(»w, clear voice ; 
whilst the tuning-fork may not be heard at all if applied to 
the mastoid, and an\- (ither sound test will be })ronounced 
inaudible. 

In these cases, besides any general treatment, such as the 
administration of arsenic and iron, a mild counter-irritation 
behind the ear will l-e extremely useful, but the use of the 
catheter or politzerization is absolutely contra-indicated until 
such time as the patient's nervous system is more under con- 
trol. In order to obtain this result there is no more valuable 
remedy than valerian, and, as its nauseous taste has no thera- 
peutic advantage, it may be administered in the form given 
in the Appendi.x. 

Malaria. — In acute attacks of malaria marked deafness is 
often a iKominent and well-marked symj)tom. This, however, 
is frequently due to a large extent to the excessive adminis- 
tration of quinine. When this is the case, if the internal 
ear be not imnu'diately affected by tiie disease itselt, com- 
])leti' recovery of tl'c hearing will follow tiie cessation of the 
exhil)ition of quinine. In other instances, even when no 
quinine has iieeu administered, a marked residual deafness 
remains, ;ind in these a characteristic reaction of the tuning- 
fork test will be noted ; that is to say, there is a great reduc- 
tion in the length of bone-conduction compared with the 
aerial conduction. 

This condition will generally rapidly yield to regular 
catheterization, togetiier with the internal administi.ition of 
strychnine and ,ir>emc. The strychnine should be adminis- 
tered, as in other cases of ear-deafness, in rapidly mcreasing 
di ises. 



Hi 



"!| 



252 



HANDBOOK OF DISEASES OF THE EAR 



This form of deafness is prol)ably due to the changes which 
take ph\cv in tlie l)l()nd in malarial affections. 

Increase of Labyrinthine Pressure.— An increase of intra- 
lahyrinthine pressurt- causes a disturbance of hearing if it 
occurs in the cochlea, and of e(]uilil)riuni if it occurs in tlie 
semicircular canals. 

Causation. — Increased labyrinthine i)ressure may occur 



{' i! 



li . i- 




rir,. 7.), — Li;rK. F.MIA : si:ction of cociili:.\, lowest part. 

A, Si al.L \ ihtiliiili ; I!, i;uiali;i tochk'ii ; C, st;il;i tym]>;iiii ; r, lU'licatc 
ntii iiliiiii (organized clot) in scala tympani, coiitainini,' nuiiu'roiis 
thin-walk'd l)l(i()<lves>;els {<■) ; o, newly fi)rnieil bono in sella tvm- 
paui ; (1*. uewlv fornu'il bone in siala vestibiili ; x, normal bone ; 
l.sp., lamina .spiralis. 

during the course of anv of the exanthemata, tvphoid fever, 
mumps, ]ineumonia, and meningitis. It may be the result of 
a sudden effusion ol fluid without any well-detennined cause, 
or, especialK' in mi<l(lle-aged and elderly peoi)le. from the 
effect of sudden cold, gi>ut, or P>right's disease ; or i)e caused 
b\- sudden driving in i>\ the stajies b\- rajiid raising of the 
atmosi>heric piX'ssure in the external meatus, as when working 



DlSl^ASLS OF rilE ISTF.HXAL I:.IU 



253 



in compressed air. Those cases known as aural epilepsy come 
under this category. 

Symptoms.— Deafness, coming on dining any acute illness, 
will often not be recognized until the acute symptoms of the 
general disorder have subsided. Wlien, however, it occurs 
in comparative health, the patient will suddenly lose the hear- 
ing of one or both ears, very frequently at night. Vertigo 




FIG. 75. — SECTION OF COCHLF,A, HIGHF.R UP THAN FIG. 74. 

A, Scala vcstibuli ; n, canalis cochlea ; C, scala tympani ; o and o', 
new bone-formation. 



is a common symptom, though it is frequently transient in 
character. The tuning-fork, even when vibrating strongly, 
will either be not heard at all, or only barely perceived by 
bone- or air-conduction. 

Suijjcctive s}mii)toms are occasionally present, and are very 
distressing. 

Treatment. — In this class of case, the hypodermic injec- 
tion oi pilocarpine, ab lecouinieaueJ uU p. 2-j<}, snouici oe 



254 



n.}xj)i!()()i< oi' ])isi:.isi:s of the ear 



R ^\ 



'^i: 



1:1 i|i 
'■• il'- 




iinployrd. Fdr the rt'lief of tinnitus, liyclrobioinir: acid 
(iliist's ut "i.). cdniuni, valerian, and strychnine, are the more 
usetul remedies, while vesication or counter-irritation over 
the mastoid are useful aids. 

Aural Vertigo, as distinguished from vertigo arising from 
diseases of othi-r parts of the system, may Ijc defmed as a 
vertigo associated with an obvious lesi(jK of the labyrinth 




FU;. 76. — SICCTION THROI GH HORIZONTAL SEMICIRCULAR CANAL. 

A, Membranous semicircular canal ; the perilymphatic space is com- 
lihtcly obliterated by new bone (h) and newly-formed fibrous 
tissue (C) ; B^, new bone-formatiou beneath endosteum ; D, normal 
bone. 

(certainly of its posterior portion, and also almost inva/iably 
of its anterior or auditory part). 

Tliis vertigo may occur when the aural disease is apparen+lj' 
confined to the conveying or to the perceptive portions of the 
aural mechanism, but true aural vertigo, arising in the ear 
itself, is always accompanied by deafness more or less severe. 

Aurai vertigo arises from liie loiiowing causes : 



MMM 



I 



i)is!:.isi:s Di- nil: /.v/'/.'A'.v.i/. i:au --55 

1. Iiitral:ibyrintiiin(j luuiuorrhagi 

2. LciikiL'inic infarcts and exudatons. 

3. Increase of intralabyrinthine ])i-essi]n>. 

4. ("iixmI iliniinutinn of inlralabyrinlhiue thud. 

5. Bright lights and noises. 

The most frequent causes of vertigo which may l)e mistaken 
>r aural vertigo are flatulent dyspepsia, circulatory disturl)- 




FiG. 77. SECTION OF API-X OF COCHLliA, SHOWING Llil K.tMIA CLOX 

COMMKNCING TO ORGANIZi;. 

anccs, and neurasthenia. In these cases, when there is any 
disturbance of audition, it is recovered from after the 
attack. 

Finally, there is a vertigo due to a disturbance of the circu- 
lation of the nucleus of the vestibular portion of the eighth 
nerve. In these cases arterio-sclerosis is the active factor, 
and an increased blood-pressure combined usually with over- 
work. 



i 






m 



II 



If. .?■: 




25h UAXn/'O'JK (,)/•' /;/.S7:.!.S/:'.S' O/-" Till: llAli 

1. \'i;kti(.() iiiu-: lo JLkmokkiiage into niii Labvkinth.— 
riiis is a rare conditicn, and is ihie to tiu; ru})ture of an 
aitcriok' ol the vi'stihule, and forms the Rreat exception to 
the general rule oi disturbance of hearing acconi])an\'ing aural 
wrtigo, for it a h;eniorihage is small in amount tlie damage 
i^ local, and that divisii'U of the labyrinth alone is affected 
in wliich the k'sion exiits. The original cause is arterio- 
sclerosis. The attack is rarely repeated, but leaves a per- 
manent injury, as may at times be evidenced bv a prol(jnged 
want of co-ordination, and later by evidence of want of irrita- 
bility as shown b\- the rotation and calorific tests. 

2. TliflwliMIC ll.liMOKHIIAGES AND INFARCTS. — The Condi- 
tion now imder consideration is known as .Meniere's disease. 
(,'ustoni and carek >sness ot dicti(m has groujied all cases of 
aural vertigo, when combined with ileatness and tinnitus, as 
Meniere's disiMSe, but if the term is to be retained, it shoiUd 
be restricted to tlie^e k'ukiemic cases. Naturally, one only 
linds this lomi in person- sullering trom one or other of the 
k'ukiemic -tateso' ^.le blood. 

The infarcts into the interi.d ear are usually bilateral. 
Ilk \' occur without jnevious warning, and are accompanied 
by or cause s>.vei ertigo and ny.-Magmus, occ.isional loss of 
Consciousness, sickness, vomiting, and deafness, more or less 
coni])k'te. Of the.se symptoms, two gradually disappear^ 
lir-t the vertigo, then the tinnitus — but the hearing power 
is not ri'covt'red. 

The li;emonliage takes jilace within the lymphatic sac, either 
tilling or compressing the membranous labj-riuth with clot. 

Ti'.is (lot, toiined i)rincipall\- of white coriniscles, becomes 
org,ini/ed it the pati( nt survives, as is frequentlv the case. 
The whole clot becomes ossified. Sometimes so extensive is 
tills os^it!(^ltio^ that the membr.mous semicircular canals are 
rejireseiiled b\' the physiological can.d alone (i'ig. yd), whilst 
in the coehlea the org.iii of Corti. together with the membr.ine 
ot Iveis-iier. ma\- be converted into boiu-, .ind the various 

si,,i! 1 reniain tilled with. ol!;.ini/cd clot- 
It i-- quite oi)vious tji.it no treatment is .ivail.ible for the 
ai.diti'iA iroubk'. 



m^ 



DlSFASnS OP Til I- ISTIRSAl. I'.AR 



-?7 



3 iNCi HASE OF Intkalabvkin'THIne Pki-ssuke. —There is 
but little direct evidence as to excess ot intnit\-inp.iiiic tluids. 
but cases occur in the exanthemata, inunijis, meningitis, etc., 
which are probably due to some tenijiorary increase in i)res- 
sure. Qiissan workers suffer from vertigo if the air-pressure 
is increased too rapid!}', the stapes being forced inward, and 
thus the intratympanic tension is momentarilv incre<ised. 
Again, those cases of vertigo which have been classed under 
the heading of aural ejiilepsy sometimes have labyiinths un 
usually large, and containing far above the average amount 
of intralabyrinthine fluid, though wheth.er this is a cause in 
itself or merely a predisposing cause there is no evidence to 
show. 

4. Vertigo due to Diminution ok Absence of Intra- 
labyrinthine Fluids. — This form is always combined with 
deafness. Frequently the deafness is of long standing, the 
vertigo appearing as a later symptom, rarely, however, before 
the age of torty. The attacks sometimes incre.ise in fre- 
quency and violence, producing agaro])hobia, or it not. re- 
maining apparently about a constant frequency, may even- 
tually disappear. This hapi)y consummation is, however, 
rare, and one cannot state with any probability what length 
of time must elapse before it occurs, nor is it easy to foretell 
in which cases the vertigo will cease. The l)est aid to prog- 
nosis is when the intervals between attacks steadily increase, 
whilst there is a corresponding chniinution m the severity ot 
the attacks. 

The arterial tension will be high in these cises. 

Treatment. — The drugs whii h are of value ,ire tlie iodides 
and hydrobromic acid, which may be e.xhibited as tor .nteno- 
sclerosis generallj'. Beyond this, quiet and ^.ww must be 
enjoined. Xo local treatment siiort ot (iper.ition i-, likL'jy in 
be of any avail. 

5. Vertigo c.xused by Bright I.K.iirs and Noises. — 
These would ;it first sight aj'pe.ir to he o| nrun>ti( origin, but 
in reality <Tre not so, but owe their existence to some obscure 
cerebral condition. 

Trcdtinoit. — In the former, a most searching oplitlnlmic 

17 



258 



Jl.lM)l!()(H\- OF DISEASES OF TlIF I' lU 



examination should be insisted on. and any irregularities of 
vision correeted. In the latter, some form of sound deadener 
should be emi)loyed as eonstantiy as possible. :id valerian 
and l)romide admi; istered. 

Non-Aural Vertigos simulating Aural Vertigo -Vertigo of 
Central Okigix. or VicRTKio arising from Causes React- 
ing ON line Central Nucleus of the Kk.htii Nerve. ~A 
condition reiidih' confused with a perii'heral verLigo, and in- 
asmuch as the jiatient is most likely to seek advice for aural 
trouble, it is well to ;illude briefly to the salient points. 

Liki' all conditions principalis- due to artcrio-sclerosis, early 
morning is the ]irincii)al time of the attacks. The attacks are 
always traceable to over-strain or over-exertion. They are 
transitory, and without anv marked increase of deatness, or 
if that coexi'-t'^. there is no obvious connection between the 
vertiginous attacks and the loss of hearing ; and when appro- 
jiriate tre.itnu'nt is adopted, the hearing jxiwer improves and 
the vertigo disapi>ears. 

Vertigo of Goitv and Dyspeptic Origin. — In this class 
of case. a]Kirt from signs of dysjiepsia and symptoms of gout, 
it wi'l be lound that during the vcr*'go there is marked deaf- 
ness, which is transient, clearing uj) r.ii)idl\ alter the attack. 
Vertk.o from i)iminishi;i> Arterial Tension.— These 
patients have often a deaf car, and, apart from one symptom 
■ — /.('., i\ce--.-ive vertigo —on rotation one fmds it diri'icult to 
describe s|iecilic signs for its detection, but dimimition ot the 
blood pres-^iut' during and after the attacks is ch.iracteristic. 

Tri;.\tmi'.nt. For the apo]'lectiform variety no s])ecial 
treatment devtitrd to the e.ir is of ,in\- avail. In the I'ro- 
gressive torm. hydrobri-niic acid, iodidr nf ))(it,issi(un. arsiiiic, 
and. 1 Iter, quinine, either in large or small doses (Ai)pendix), 
are the more serviceable internal remt'dies. though it there be 
much nervous excitabilitv the bromides will be suiurior. 
'1 he rttect oi pilot, arpiiie m.iv also be tried. The ouly local 
tK.itnient w liii li ap|>e,\rs to h.ive an\- beneiici.d ellect is the 
Use oi the (oust. ml oi high-frequeuev t urri-nt, one pole being 
pl.u ed o\-er the m.istoid process and the other .it tlu back of 
the neck. \'er\- weak currents should be enqiloyed at the 



DISHASLS OF TUB IXTJ:RX.IL FAR 



->') 



coniiiU'iicciiK'iit, and the sitting should be oi sliort duratmn. 
but should lie repeated daily. This should not be enijiloyed 
at the coniinencenient of the disease. 

Operation will in all but cases of central origin cure this 
condition. All forms of treatment failing, recourse may be 
had to operation. The essential is that the vertigo Ik? of 
aural, and not general <n- central origin. The same operation 
is ])erformed as in supjiurative labyrinthitis. The results are 
mo<t excellent, and the patient is quickly relieved of his 
trouble, and A'hen the patient's livelihood or general comfort 
is coi!sickM\il, no hesitation need be felt in recommending 
vestibulotomy. 

Inflammation of the Labyrinth, or Otitis Interna. -This con- 
dition, most Irequently a complication of suppurative disease 
ot the middle e.ir, may be secondary to tul)erculous menin- 
gitis. Tr.iuma is responsible for a certain numlK-r of cases 
when fracture of the base of the skull has extended from the 
labyrinth, and suppuration has followed ; also a case has been 
reporti'd in which se|nic disease of the labyrinth followed 
an injury, a needle being pushed through the niemlirana 
tjinpani, and drivmg the footplate of the stapes into the 
vestibule. 

The condition inav itself be followed oy general sepsis, 
meningitis, extradural abscess, sinus py;emi,i. or brain abscess 
—usually cerebellar. In other instances it will be lollowed 
by necrosis of the labyrinthine (-ai)sule, a condition which 
lias already been alluded to as a sequel of suppurati -ii in the 
middle ear. 

The symptoms will usudly I'e ushered in with liigli lever, 
though in chronic cases the temiHr.iture is not raised, with 
intense vertigo, a tendency to fall towards the side aliected, 
or it may be to the sound side, nystagmus, a,nd vomiting, 
absolute deafness when the coclilea is involved, these symp- 
toms being frequently .iccump.inied by a severe tinnitus. In 
acute cases the attitude oi the p.itient will be ih.it of cerebnil 
irritation. I'he vertigo is a transitorv sym|)toin, hut the 
tinnitus is :\\>\ to rem nn. This condiliuu was tirst descniied 
early in the last ( cntiMv. 



Hi 




II ill 



260 



II.i.MJllOOK OF UISFASES OF TUF FAF 



The recdgiiilion of labviinlliinr iavnlwinent in the course 
of inihiinni,!t(>r\- disease in its immediate vicinity, or invasion 
of its cavities l)v anv jxithological process of suflicient in- 
tensity to tlestro\- or dejn-ive of the power to respcind to 
stimulation of their ph\-siological function, is at the present 
time nioic clear than when the last edition of this handlxK^k 
aj'peared. 

For tlemonstration of the loss of function of the cochlea 
nerve, see Tuning-Fork Tests. 

In order to demonstrate the loss ot function oi the vesti- 
l)ular nervt', one has recourse to two main tests — the caloric 
and rotatorv. The former is the more reliable. The caloric 
test is (lone by gentlv irrig.iting the ear with water below the 
temperature ot 60° F., emjiloying about 6 ounces. The 
rotator\- bv rotating the ])atient, either with eyes clo>rd or 
covered witl; ojiaque glasses, ten times in about twenty 
seconds. In the cal(uic the ]iatient's eyes are fi.xed on the 
observer's finger either directly in Iront or to the opposite 
side. If the patient h.is a norm.d or irritable vestilnilar 
nerve, nystagmus is n()ticed. If no nystagmus is noticed, 
the nerve is not irritable, and if there is also scere vertigo, 
there is either a fistiila into the labyrinth or a hyper-irritable 
nerve, fn this test, with a normal nerve, the greatest ex- 
clusions of the nystagmus are towards the opposite side to 
that tested. 

Warm water gives the opiKisite results, but with hot water 
regular results are not to be obtained ; therefore the test is 
always to be made with cold w.iter. 

The Rotation Test. — The patient is rotated first to the right, 
and after the result^ ;ire noted, to tiie left. 

I'he rc'-ult'- in this test are thus noted : Ten rotations to 
riglit=.v secoiuls 1 his means that a\U'V rotating the patient 
ten times a nystagmus is obtained on tixing the eves which 
hist X second- in tin- n'Miu,!! ; this is .ibout t wen t\-- live seconds. 
W'lirn t'le 1 iliv.rinth i'- not irritable no nystagiuus is obtained ; 
when niiu li diminished it becomes lessened. I'ntortun.itely, 
tliis test i^ i>f less vahii the longer the perio^l of time whicli 



.. ..1 



.,,1 ^ii,, 



tlx. 



tlw> 1> 



IP '-^ 



DISEASES OF THE INTERNAL . AR 



361 



more and more dependent upon the remr.ining labyrinth. As 
the effects f)f rotation are probably dependent upon changes 
in the l)lood-j')ressure, one scarcely relies upon them. 

Perforation Test. — When there is a fistula into the bony 
external semicircular canal, compression of the air within the 
meatus causes nystagmus and vertigo, with a tendency for 
the patient to fall towards the affected side ; but when there 
is a large o]HMiing into the vestibule with destructiou of the 
endosteum, the tendency to fall will be awav from the lesion 
when the ear is s\ringed or the air in the meatus is com- 
pressed. 

The nystagmus is usudly towards the sound side, but 
when towards the affected side it is probibly in those cases 
where there is a perforation of the membranous as well as the 
bonv labyrinth. 

Treatment. — Treatment will consist in removing, as fai as 
possible, that jKirt of the bony labvrinthine capsule within 
which the disease is situated, except in cases where tlie affec- 
tion is due to a prolongation of infection from the cranial 
cavity In order to do this a radical mastoid openition should 
Ix" hrst performed. If a sinus be found into a canal, esi)ecially 
the e.Nti'rn.il. should the symi'toms indicate ojnration, that 
canal should be opened and the canal followed mitil the 
vestibule is opened, and where advi'--,able a second opening 
can be made by remov.d of the sta]ios and enlargement of 
the foramen ovale downwards and forwards, at the same time, 
by cutting away the im-montory, oju'iiing the lower end of 
the co-.lile,: If a sinus is found in the region of the foramen 
ov.ile, it will in like manner be folhiwt i ui) (for details, sec 
iuilc). The general after-treatment differs in no respect from 
that given lor tlu' radical mastoid op. r.itiou. 

Neurasthenia of the Auditory Nerve, or Weakness of Hear- 
ing, r.\thiNi>t< be understood , I I'onditiou (it temjM r.irv loss 
111 limction, or of cmuluctivity, l>v the auditor}- nerve, due to 
extr.ineous eaUMs, uhieh, acting oii ,1 j),nt .dready the subject 
ot some sligli' pathological lesion, is readily attacked. iliis 
(-ondition includes nianv which are also considered under the 

■ ! ■! ; i '. ! *.-.-'■' ^' 



iii«e> >'i 



iViiti-iiiia 



1 1_\ J'V 



262 



HAXDDOOK or DISEASES OF THE EAR 



i 



P' 



m »R! 




The principal active exciting causes are overwork, both mental 
and bodily, worry and anxiety, over-indulgence in food, drink, 
or sexual intercourse, and malaria. When the cause is over- 
indulgence as tar as the ingesta are concerned, it matters 
not whether this is actual or only relative to the habit of 
body and to the amount ot exercise. Vertigo and tinnitus 
are frequent concomitants of tln' deafness, and is at times 
paroxysmal, a i)seudo-Meniere. The principal diagnostic 
featiu'es of this class of case are the histor\-, together with a 
loss of bone-conduction quite out of iirojiortion to the loss 
found in voice and whis])er tests, or in the case of gouty 
trouhlc ; at times the intermittent character of the trouble, 
its exacerb.itioii-,. and rei-owries. 

The.\tmi;nt is largely general, and directed in the first 
instance to a correction of the constitutional trouble, and 
when this is corrected attt'iition is to bf devoted to the aunil 
lesiiin, usually middle ear ; and here, as in all aural lesions of a 
hysterical and neurasthenic tyi)e, inflation should be avoided. 
Rest and change of scene are the two most elfective adjuncts 
to ircitment. Kspecially valuable is a sea vo\-age. 

Neuritis of the Auditory Nerve — C.msatiox. — Toxic .scarlet 
lever, typhoid, mumps, and a few other of the exanthemata, 
diphtheria, intluenz.i, and rheumatism ; drugs, as quinine, 
saliciiK', alcohol, lead, and |)ossil)ly tobacco. 

The toxic agents which affect the auditory nerve cither 
c.aise a permanent or tem])or.irv loss of function. Of the 
latter are tho,o caused by drugs, and are capable of being 
recovered Irom when the exhibition of the drug i- discon- 
tinued. In this connection it is well to revert to the condition 
rett'iied to ,is neiir.isthenia of the aii(litor\- nerve, under which 
he.idmg mal.nia was included ; for oiu- tinds no deafness re- 
maining alter the administration of qmniiie unless in.d.ui.i is 
also ]ire^eiit, and .ilthough in ears witli deleclive vessels per- 
m.ineni injury »;//,'///' be done, yet there does not seem to be 
aiu' suhst.mlial ptoof of this beliet. 

1 he toxins whirii ciuse de.ilness, and during the course of 
the v.irious levers aic permanent, and, as has been demon- 
strated in diplithena, are due to direct iidection of the lai)y- 



DEAF-Mr^TISM 



2^3 



rinth, are, tlien, clue to direct action of the virus upon the 
end organ of the nerve. 

Symptoms. — In most of the cases of fevers the deatness is 
only noticed some time after its prohal>le onset, but httle is 
known of its causation ; but in rheinnatism tiie attack is sudden, 
and often accomixuiied by Meniere's comi)h'X of symptoms. 
In alcohoHc and tobacco poisoning the effect is gnidual, and 
neitlier vertigo nor tinnitus are present. Tinnitus and vertigo 
are almost inv.iriably transitory. 

Tre.vtment. — Antijjyrin is advocated as a useful drug, but 
few data respecting its employment are available. Pilcarpin 
administered b\- h\iiodermic injection is the most universally 
employed drug, but must be pushed if any good effects are 
to be ol)tained. 

Primary New Growths of the Internal Ear.— Primary new 
growths of the internal ear are comparatively rare. fhey 
may be sarcomata, neuromata, or epitheliomata. They will 
rapidly spread into the surrounding bone, and will, if the 
disease be malignant. i)enetrate into the cranial cavity. 
If the growth, however, be innocent, as a neuroma, the 
sxnni'toms will vary according to the site and situation of 
the growth. 

DEAF-MUTISM 

Deaf-mutism is either congenital or acquired. The con- 
genital form is due to a non-development of some portion of 
the l.ibyrinth, the most constant of these errors of devi'lop- 
ment being absence of one or more ot the semicircular canals. 
In these patients no perce])tion of sountl cm be discerned. 
They may be tested with loud sounds, as bells and whistles, 
or by the sharp sound pnnhiced by a jnece of Hat steel bent 
r.ipidly to and fro. 

No treatment can be of any avail in these cases, and the 
sufferi'rs siiould be instructed early in lip-reading. 

Acquired Deaf-Mutism. -Acquired de.il-mutism is due to 
some inti.unm.ttory change either in the middle vav. the 
labyrinth, lu the auditory nerve within the crani.d cavity. 
If a child who has not learnt to speak suddenly loses his 



I H 



'*'i| 



,ii; 






264 



HAXDBOOK or DISEASES OF THE EAR 



hearing, he will become a deaf-mute. Such a calamity occa- 
sidunlly fdllows acute diseases, as meningitis, scarlet fever, 
mumps, and the exanthemata in general ; concussion of tlie 
brain will sometimes cause it. 

Tke.\t.mi:nt. — Ii; patients in whom all percei)tion of sound 
is entirely lost, as carefully determined l)y the use of hearing 
tests, we have little to hojje for from treatment ; in sufferers 
wh) retain any jK'rception of sound whatever an endeavour 
sho lid be made to restore the function, and in such cases 
adenoid vegetations, if present, should always be removed. 
At the same time it must be clearly understood by the ])arents 
or friends that the operation in itself is only an adjunct to 
aural treatment, which consists in regular inflation for two 
or three months, and in the administration of nu.\ vomica, 
with occasional doses of hydrarg. c. creta. It is, unfor- 
tunately, rarely that we obtain any result by this treat- 
ment, but, nevertheless, it should l)e given a trial. If it 
tail, the child In to be put under proj)er instruction in hp- 
reading. 

Urbantscliitsch has recently reintroduced a form of treat- 
ment in vogue in the early ]),art of last centur\ , which is to 
enable those cleat-mutes who still p()ssess a dormant remnaiit 
ot hearing-power again to exercise that remnint, and to build 
upon it ,in increased audition. This end is olitained by the 
use of methodical acoustic exercises, which mav be said to 
have a threefold olijeet : "irst, to awaken attention to acoustic 
im])ressi(>iis ; secondly, to build up differ<>ntial hearing ; and, 
thirdly, to incre.ise acoustic excit.ihility, Xo case should 
be considered unsuitable imtil the acoustic exercises have been 
tried. They are not so suitable in school-children as they are 
in Liter liie, on account of the gre.it pains which must l)e 
taken in order that the exercises ma\- produce any result and 
the l.irge amount of lime .eciuiii d. Neither can the result 
be foretold in ;in\' individual case ; nor should the inability 
to iicir tuning-torks thmugli the cranial bones be considered 
as a li.M to tre.itment. 

1 he iMc.itir the dif!Lcu!t\' tliere is in arousintr t!'.'.' nercer!- 
tiou (i| sound, the more are spe( ial exercises required. Ihesc 



n ' 



n •^^l.i^dKd 



' 



DEAF-MUTISM 



365 



latter maj- be omitted in the event of the patient hearing his 
own voice or perceiving ordinary sounds. If the sHghtest 
acoustic perre]itioii is awakened by the exercises, tlie case 
immediately !)(■( .mies suitable for further treatment 

Tlie metliod of Urbantschitsch is brietly as follows : Two 
vowels are selected —say (i and n, as they are the more readily 
understood. The one to ]h' used is lirst indicated to the 
patient by the lijis, and then is spoki'u into the ear in a loud 
and ])rolonged voice. This must be repeated until the patient 
perceives the sound. This may not be for several sittings, 
and it is better that the sittings should not be too much 
prolonged, but they may be often rejieated. As so(in as the 
first sound is heard and pronounced by the patient, the second 
vowel sound is emploj-ed to enable him to commence arriving 
at a differentiation of sound. One vowel after another is 
added, until the patient has mastered all the vowel sounds. 
At each subsequent lesstm a consonant is added to a vowel, 
until the rudimentary vowel and consonant sounds are both 
perceived and difterentiatecV Gradually more syllal)les and 
combinations of sounds are employed until words are formed, 
and eventually complete sentences, the distance from the ear 
being increased as the exercises progress, and as soou as jios- 
sible lip-reading is abandoned, and the exercise becomes purely 
acoustic. As soon as })ossil)le also it is advisable to connect 
the sounds made with some object which will ajipe il to the 
other senses of tiie sufferer. Urbantschitsch liunself says 
tliat the lessons should not last more than live minutes to 
commence with, nor occur oftener than once a day ; but as 
the patient progresses, so may the time limit and frequency 
of the seances increase. Above all other factors, regularity 
and the close adherence to a system are necessary ; also the 
t';;""li''i' ri'quires to })ossi':n a ck'ar and sonorous voice. This 
method may also be emi)loyed to relieve in some degri'e the 
deafness of chronic catarrhal deafness 



i 



■P 


fff?^" 



p. < -. 

ii\ 

i II • 

1 r^ 


9 



266 HANDBOOK OF DISEASES OF THE EAR 



UNILATERAL LOSS OF HEARING OF CHILDREN 

Cases occur quite frequently in which patients, children of 
tender years sonictimes, are noticed to be a little wanting in 
attention, and as they get older it may be discovered f)r sus- 
pected that the}' are somewhat deaf. A careful examination 
will reveal in some of these cases that one ear is completely 
functionless. that neither bj' bone- or air-conduction is there 
anv a]i]"ireciation of sound. At the present time the cause of 
this entire loss of function is quite obscure, but the remaining 
ear seems to get its function or powers materially increased, 
so that the patients frequently are not aware themselves that 
they are absolutely deaf on the one side, air and bone- 
conduction becoming enormously increased in the sound ear. 




iiji^f 



CHAPTER XVI 
LIFE ASSURANCE 

The Influences of Diseases of the Middle Ear on Life 

Assurance. 

It will be advisable to consider this question under the four 
following symptoms: Deafness, vertigo, tinnitus, and sup- 
puration. 

Deafness. — The influence of deafness directly upon life- 
expectation is not great, but a deaf man cannot be considered 
as an absolutely first-class life. He runs necessarily a greater 
risk of accident than does a man in full possession of his 
faculties : severe deafness in a young person who is insuring 
his life for its \vh«''e period should certainly subject him to a 
moderate incre; the premium — that is to say, an addition 

of five years or i. re to his age ; a young individual affected 
with otosclerosis should receive at least ten years' addition. 
In later life — fifty years and upwards — the load need be no 
more than five years for absolute deafness. 

Vertigo. — Vertigo, especiallv ii severe and if the attacks 
are accomixinied by Meniere's symptoms, will necessitate a 
very heavy increase in the premium, or even an absolute 
rejection of the life. 

Tinnitus. — Tinnitus, uncomplicated, is only an important 
factor when the applicant for assurance is of a neurotic 
tfmpcrament, and has begun to find the tinnitus intolerable, 
or when tlie tinnitus hi>^ rommonced to take the form of 
voices ; in the former instance the possibility of suicide must 
be taken into account, and in the latter the probability of 
the o!is(*t (»1 insanity. 

Suppurative Disease of the Middle Ear. — After the occur- 

267 



268 



HANDBOOK OF DISEASES OF THE EAR 



rence of a single attack of acute otitis media, followed by 
complete restoration to health, a person is not rendered unfit 
for life assurance at the usual rates. 

An applicant who has suffered from chronic purulent disease 
of the middle ear in wlmm the ])erforation has healed, and 
who lias been free from s\'mptoms for two years or upwards, 
also needs no addition to his i^riMnium. An applicant in 
whom a perforation exists, but in whose condition there his 
been no aciive change for two years, may be accepted with 
a slight addition to the premium. All candidates who are 
the subjects of a chronic supj)urative otitis media, no matter 
where the perforation is situated, nor how scanty the dis- 
charge, nor how long the periods between recurrent attacks, 
should be absolutely rejected. This rule of practice may be 
modified to this extent : If an applicant place himself under 
treatmer and report himself at a later date as having been 
cured for more than two years, the medical referee may then 
accept the proposal with an addition of five to seven years to 
the life. On the other hand, if the apj^licant has submitted 
to the radical mastoid o])eration with a successful result, no 
addition need be made to the assurance premium. This 
operation can onlv be called successful from an assurance 
point of view when tlie cavity remains dry and free from 
cholesteatoma, and is capable of free inspection through the 
external meatus. Xo ajiplicant who has had an abscess of 
the bnun should be accepted until a period of at least ten 
5'ears has elapsed since the symptoms subsided. 

Those alfections of the external ear which would cause 
rejection would be the occurrence of malignant disease. 
Lui)us of the external ear would entail the applicant being 
deferred until the disease had been eradicated and had 
remained cured for two years. 

The general i)rincii)le underK'ing the treatment of a]>plicants 
for life assurance with su[)purativc otitis media is that the 
applicant is suffeiing from a cui,ibU> disease, which as long 
as it remains untreated is dangerous to life, and that to an 



mi 



• riiWirtftt 



Lll-E ASSURANCE 



369 



Investigation of Cases coming under the Employers' Liability 
and Domestic Servants Acts, etc., and of Malingering. 

Tlie most frequent class of case will be found to be those 
coming under the general term trauma. 

In children, the effects of boxing the ear. 

In servants it is probal)le that deafness attributed to colds 
or to the effect of illness, and even suppurative otitis, may be 
complained of. 

In workmen, caisson deafness and the results of injury to 
the labyrinth from concussion or fracture of the skull. 

In malingering one usually finds a history of injury or 
malaria, with either complete or mcn-e commonly unilateral 
deafness. 

In the case of ruptured membrane, if due care is taken no 
ill-results will occur ; but if from ignorance or carelessness 
suppuration ensues, one must, in calculating the time required 
for a cure, and the probable loss of hearing, be very guarded— 
in fact, it would be impossible to give an opinion of any real 
value. 



ti.'t I 



ill 



§" 



APPENDIX 

r( )\vdi':rs. 

For Xasal I.avai.k. 

I. li Sodii chlorid. j 

Si)(iii l)il)or, i • • 

Soilii l)itarl). j 
Sacli. all). . . 

,~i- in ,"'v. of t(])i(l wattT. 



aa -I. 



I'oK SvMi'TOMS or Mi;ni.\(;i;ai. iRRiiAiioN. 

2. R Ifvilnu;;. suIkIiIoi. \ .. , 

Ouinin. sulph. ( •• •• ''-^ Ki"- v. ad x 

Tlif powder to be j^ivcn i v ry tour hours till 
ti'iiijHiaturo ialls. 

For Usi; in \'i;kv Skvicri: Casi;s or .Mi:nikki:'s 
Disk ASK and ()iai.'-.ia. 

_j. II (hiiiiiii. sul])li. .. .. .. j;r. XX. 

l"t. pulv. Taki one every four hours. 

^. K (»uniiii. lulph. .. .. .. ^Y, x\. 

.\c. iiydroDioiu. dil. . . . . "i. 

Aquiiin ad r,i 



i 



MIXTIKI'S. 

5. ii l.i(j. hydrarf^. ])eroiilor.j 

Sp. vini rect. j- . . 

(ilycerin. j 

l''.\t. I incliuiia Ihi. . . 
Ai|uani 

M. ; It. dosis. Thrice daily. 



aa ,,• 

111 xx. 

ud ,-,i. 



.^km 



AITLXniX 271 

For Usk in Tinnitus. 

(). R Tiiict. valtT. aininon. . . . . Tjss. nd ."i. 

Sp. <un. lou. aroinat. .. .. \\[\. 

Ai|uani . . . . . . . . ail ,-,i. 

M. ; ft. (losis. Thrice daily. 

7. K .\c. liydrohroni. dil. . . . . n\ xxx. ad .~i. 

S]). clilorofonn. . . . . . . 1)[ vii. 

A<|iiain . . . . . . . . ad f,\. 

M. ; ft. dosis. Thrice daily. 

8. R I.i<i. strvchniii. hydrochli)r. .. \\[v. (increased 

to ]][ \.) 
Ac. nitrohydrochlor. dil. .. n(^ v. 

;'(■/ .\c. hydrolirom. dil. .. Il[ xxx. 
AqUiU . . . . . . . . ad ,-,ss. 

M. ; ft. dosis. Thrice daily after food. 
Increase the dusc by ll( i. until m^xii. per dose is reached. 







LOTION'S. 






I'OK SVK1N(;IN(, 


Tin: li.\i<. 







I.ysol 


. . 


10 




Creolin 


. . 


11 




I/.,d 


. . 


IJ 




Sol. h\'(lrar^'. ])eichlor 




1.5 




Sol. liydrarL,'. hiniod. 


. . 


14 




l'"ornialin 


. . 


1.5 




.\c. Ixirici 


. • • f 


i() 




(ilvcerin. ac horici 
(ilycerin. ac. carholici 

Aijuani 


1 
I 






M. ; ."iv. in 


,1,1 .-,iv. 



}. to ^ per cel't. 

.1 to J ])er cent. 

.1 to 10 ])er cent. 
.I'li '•» I'l, percent. 
.;',, to ,',, ])ercent. 

,',, to I l)er cent. 
|.;r. v.-xx. ad -j 

aa ."ss. 
ad -,v. 



GUTT.E. 

1 7 R S|)i. \-ini rect. . . . . . . .-,i. 

T\ven!\- diop^ to i)e w.irnied and dropped into the ear. 

1,S R .\c. 1mm K 1 . . . . . . K'- >'• 

Sp, vini rect. . . . . . . ,-,i. 

M. ; it, guttic. As m i"orniul.i 17. 



m '^ 



272 




ILIXDIIOOK 


OF 


L»/5/ 


".i SLS 


(>/•■ 


r//L' 


/:■ 


-i/e 


K). 


R 


Hv 


1. piTCll 

Villi i\( 


lor. 
t. 
M. 


; ft. 


KUttiU 




• 51 







m 



H : 



JO. 11 Ac. salicyl. 

Sj). \-ini rcct. 

I. ill. ainiiioii. .icftat. 



^r. V. adgi". -\.\x. 
.~ii. 
, . ;ul r^i- 



:i. R rcroxiilr ol l.yiinM^fcn (10 vols, stivngtli) 
.\s in I'ormuhi 17. 



■OR SdlTHNING ClKLMKN. 



J. R (ilycnin. \ 

.Xniuu <lt'st. J 



aa ,-!• 



jj. R .-^odii bicarb. .. .. .. k'I"- ■"^>^•'^• 
(Il\■(■(■rill. . . . . . . ."ii- 

.\(iuani . . . . . . . . ad :,i. 

A- in I'orniula 17. 



.\x.i;sth1':ti<: soi.ii;' >'s. 

AlK.M. USK. (iKAV. 

. . liV. X. 

. . aa ",1. 



j.j. R ( (iranic 

Aniline oil ) 

Rri'tilifd spirit /■ ■ 
Tins solntH^n sotin ih.in.^Ts coloni trom absnrption oi water. 



^5. R Siij. ciiciina', S per cent. | 
Sol. roiaiiuu, 10 j)i'r imt.j 



aa -,ss. 



ri:mkdii-:s tor isic ix otai.i.i.x. 

j(). R I'il. belladonna' gr. J 

Take one pil. three or four times daily. 

_7. R ( )pinin aural o\()id. (Bullock and Co.) 
Oiir to l>e pushed into meatus. To be repeated in 
three liours' time if required. 

.^(S. R ChloiolfMin. 
Tell nnniiiis to be dropped into an eq^cup ami placed 
o\'( 1 auricle. 

j<), R Phenaretin . . . . . . K'- ■'^• 

Take one uowdcr thrice ilaily. 



APPEXDIX 

30. II Antipyriii 

As in Formula 29. 

31 R Morphia (hypodermic). 



273 



rr. w. 



C( )UXTER-IiiRn ANTS. 

32. R Tinct. iodi I _^ __ aa partes ;equalcs. 

I met. cantli. J ' ' 

Paint the mastoid d.-.y until soreness is produced. Rejxat 
the process as soon as the jxirt is again sound. 



&:l 



R Ouinin. bisiilph. 

In forma pulv. 

Powder on raw surface after blistering, and cover with 
oil-siIi< for tiiuutus. 

J3. R T.nct. iodi I _ __ aa partes ;c.iuales. 

Inict. capMci j ' ' 

As in I'orniula ]^. 

3-|. R l':thyl chloride. 

Use as a spray over mastoid thric(- daily. 



IXTKATVMPAXIC IXJIXTIOXS. 

35. R Sodii bicarb. . . . . . . gr vii. 

(ilycerin. .. .. .. m^x.w. 

AtiUiU (lest. . . . . . . ."li-'S 

M. ; ft. inject. Use \\ iii. warm. 



3'). K Pilncariiin, nuir. 
.\ipiam dest. . . 

As in Formula 35 



. . gr. m. 
ail "ii.ss. 



37. R Pot. lod. . . . . . . gr. i. 

.\iiuani ('"St. . . . . . . a<l o'-^'S. 

As in i'ornuila 35. 

;S K llyd. biniod .. ., .. gr. .\vi. 

l.anolni. . . . . . . ,"jVn. 

01. pet. . . . . . . ad ,=,iv. 

M. .\- ni loinnila 35. 



18 






2 7-4 



H.tNDrOOK or DISEASES OF THE EAU 

VARIOUS. 

Maxdl's Solution. 



^C). 11 lodi (crvst.) 
Pot. ioii. 
:\I(ntli()l 
Glycerin. 

M. ; ft 



gr. VI. 
gr. x.\. 

.gr. V. 



pignu'iUuni. 



MS 



:!f 



lODOFOKM EmTLSIOX. 



40. R lodofoniii \ 
{)\. liuiolini j 
01. pftiol. 



a.i ,,1. 



M. 



i^ 'J! 



ListI'.r's Strong SoU'tion. 



41. K Ilydrart;. ixnlilnr. 
Ac. carl Mil. 
AciiKun 



! per cent. 
5 per Ci'Ilt. 
. utl 100 pel" cent. 



S.\Li('YLK l'.\sTi: loR Usi'. IN Attic Cii(ji.i;sth.\toma. 



42 R .\c. salicyl. 
Crea^oti 
Einp. plunibi 



43. R Ac. salicyl.] 
I'apainc 
.Meiitliul I 



M. 



20 jM r cent. 
5 per cent, 
ad luo per cent. 



afi 33), jKr cent. 



L.XSSAR's OlNlMlNT 1-OR I'XZIIMA. 



44. R Salicylic, acid ) 
Jvesoicin. I 

Ichthyol 
LaiKilnK' 
Vastliiii' 
Zinc o.xidc 
Stairli 
In moist cc/i 111,1 tlic salnxlic .u iil slioiild be oiiiittcd 



aa gr. v. 
pr. X. 

aa ~jn. 



^ 



mitm .« ■ 



I^ii i' 



(I S! : 



!3i 
I'M 

w 



liA' 



I :i 



If! 



Ui i j|-,Tnhiiii 



I N D E X 



Ablation of cochlea, j^i 

Abscess of brain, aiul lite assur.incr, 

ccrfbfllar, iim" 

treatment. i<>i 

<'xtern.U lue.itus, v) 

extradural. if<4 

intradural. i'ii> 

lit the liibuli;, ^7 
Ae.etle etlier, 14^) 
Acid, carbolic, ;oi 

chromic. 167. i/') 

hydr>.liromir. 1^4 

hvdroc hloric dd., 174 

^.ilirvlic. 17J 

trichliir.icetie, i(i7. 17') 
Acomueter. rolit/er'>, 247 

testing by. 51 
Acoustic exercises, L'rh.mtsi hilsi h, 

Acquiri-d A-elis, 100 

Acuteness ot hearing;, estimatu.n ot, 

47 
Adenitis, izz 

Atleii'iids. 22. 2.t. iS, iiii 

,ind I'.ust.irhi.ui (ilistruction, iii 

<h.it;niisis nf, i^ 

ill di-,it-niutism, ^04 

voice in. .;s 
Adenii-s.ironi.ita. I(H>. jju 
Aditus ad .uitruui. 3. 15 
Ailren.dm. joo. jjj 
.I'IoIkui iirKan. (13 
AK<'r.i|ihi>bi,i, I (J. 2:-,7 
.\n\u\ 22 

Aids in he.trin^:. 77 
Air ( Miidiu tioii. 53 

iu.issa«e, 73 
Alcoliol. 144, I()0, 2b2 

ellects of. 24^ 

injc( tions, J41, J4 t 

instill.itioii, 2J4 
Alcoholic excess, 23 
Ammoiii.itc (1 meniirv Mintnient. mi 
Amni')inum ehliridi', imm mt s.ijM.ur, 
140 

.ViMtomv ol the ear, 1 



Andine oil, dr.iy's solution, 75. </), 

147. I ''I' 
.\iiniilar lit,'.iment. 10 
Anom.ihius residts in tuniiiM-fork 

tests, bz 
Anterior ligament <if m.dleus, d;\ibi"n 

of, i<)S 
Aiitipyrin, 2t)j 

svinptonis c.iused by, 4,; 
.Antiseptics, iS'i 
.\ntruiu, mastoid. 5, 13 
opening; ui. zdS 
tymiianii'. is 
Aprosexia of (iii\'e. .: 4 
Aqueduct of the vestibule, >! 
Arsenic, 144, 2^1, 2^^ 
.\rteno-scleriisis, 21, 235 
.\rler\-, intern. d c.irotid, erosion ui, 

170 
.\rthritis, tenip'iro-m.ixilKiry. 3^ 
.\rtitu i.d drums. 77, i«o 

e.irs. 7 J 
.\rtillerv pr.ii tice, 240 
Aspt-r)iilhts niiicrv. nihil':. 02 
.■\t,ixy. ( erebeli.ir. I'li 
.\ttic. tviup.mie. I. 7 

.leute supi>ur.ilion ot. 1 1') 
I .innul.i. Il.irlm.mn's. 102 
chronic suppur.iticin of. lUi 
.Atrnphu naso-phar\n,i;itis, ;3.S 

rhinitis. 22, ^^. 2,iH 
Auditiiry nerve, mjurii's t'l. J411 
neur.istheni.i ot. 2t>i 
neuritis ot. 21)2 
.Vur.ll epllepsV. 2^2 

pohpi. histdlo^jy. itjj 
tre.ltmellt. Ill'-) 

virli>;'>, 40, 254 
.Vuriele. horny >a"owth of. Ho 

rel.itive projection of, 27 

superiiuiiii'rar\', 7') 
Aiisctilt.iturv tube. In. no 
.\ut.i-inllali.iii '>t the t\nip.uiiim, ijS, 

14 I 
.\ul"pluMii.i, 43. 103. 131, 137 



Uiirii'v, ncusi'.pr.nlucer u(. 4'/. '>3 
Uark. itij 



277 



inr 



in; 



27S 



n.}\D!IOOK OF DlSFASr.S OF THF EAR 



l^.'W. 



li'- 






H.ittry's '^olutinn, il'"! 
Haf till' slio' .tint;, 24!) 
Hrll.idonii.i ,uicl filyctrinc, IJ3 
Hi H's ii.ilsy, IT'S 
H(ii/.(ii(' va|u>ur. 13:: 
Hcnzoin, tiiuturo, in 
Hczold's iu.isti>iditis. 12?, zo\ 

ojiiration in, 210 
liluwint; the nose. 114, i.\'). 2)0 
HuiK r makers. 246 
H(inr-con(lu('tion, ?5 
Bony growths. 07 
Boracic acid. 150 

solution. iii 
Bordir oi-lls. 16 
Hou^ics, Kustaihi.m. 74. in 
Hour^jct, electric sunnd apparatus. 63 
IJoxiiifj ears, in children. 26c) 
Hr.idve.irdi.i. i i 
rir.iiichial clefts, site iit. 79 
HridKc. the. 217 
HriLrht's <lisease. 232 
Hroiuidcs. 23S 
Hurr, electric 206, 216 

hand-power. 206 

C.iisson de.ifness. 269 

workers, 2S7 
Ciissnns. 23 

Calcireoiis (lecener.ition, nieiulir.m.i 
tvmiiani, 179 

patches, 311, 148 
Calcium chloride in luriuu ulosis. 96 

hictati'. 130 

lihosph.Ue. 130 
Calomel. 1S4 
Caloric, tests. 260 
C.iimnla. ii.irtmann's. 128 
('.irluilic acid. 21,1. 224 
Carcinoma. si)nanious-celled. 236 
Cities of ossicles. ISO 
Carlsli.id salts. 144 
C.it.irrh. post-n.isal. 3*") 

serous, of middle e,ir. 131 
C.iihetcr. I'nst.ii loan, ii(' 

mli,itit«n thri>ut;h, 14 t 

injection tlirMut;li, 115 
Ca\ um tvmiMni. 4 
Cephalalgi.i. 1H3. 1.S5, 19? 

frontal. 38 
Cen li- liar ataxy, i()i 

.iliscess, 41, 190 
Cerebral al)scess, otitic. 1^6 

tre.itment. 1S9 
Cerebr.ltloii. del.ived, I.S7 
Cireliro-spm.d tluul. 235 

menini;itis. 248 
C'Tinnen, 3 

excess of. 102 
Ceniminiius >;l.inds. disrases of, 102 
Chi'\ ne-Stokes respiration, iS 1 
I hlllil.illi^. J.' 



Children, ioreifoi bodies in ear in, 107 
ne( rosis tempor.il lujiie in. 173 
otitis medi.i. acute, in. 114 
tuliercul.ir dise.ise of teiiipor.d 

bone in. 129 
unilater.il loss of he.irinf; in. 2fi6 
ChliirofnriiL vapour lor insects, 108 
( lioked discs. 191 
Chnlesteatoma. Is9. 'i(>^ 
)i.ithology, 1O8 
treatuK'nt. 170 
Cliolesteatoniat<ius change, 155 

degeneration. 20.S 
Cholestenn erxstals, 170 
Chcjrda tvmp.uii. 7. 10 
ChrDiiiic acid. 167. 179 
( lininic dry catarrh. 134 

non - suppur,iti\e disease "i 

middle ear. 134 
sepsis. I. so 
supiniration nf middle e.ir. 

se(|Uel,e. 177 
suppur.ition >A tviup.mic .ittic. 

161 
sii|ipurative dise.ises nf middle 
car, I, so 
Cigarette smoking. 144 
Circulatorv disturb, uice. 2s,=i 
t irciimcision of th<' stapes. i''<0 
Cl.iv. I'lwksley's, 87 
CUlll.lt( . 22 
l.n(,unc. i.^o 

an'.ine oil solution. 75. 96, 147,180 
111 ■ atheterism. 6(,. (>S 
m Misteriiir rhinitis. 5 \ 
Ccchha. 7. 8 

.ibbitiou iif, 2 i3, 244 
disease of, 247 
nd-liver oil, i()i 
nlfee, 144 
olds, 20 
oll.i]ise I if miiuth of externa! ine.itus. 



ill idiiin, I 19 

implic.itiiiiis, iiitr,n r.ini.ij, 1^2 

di.ignnsis lit, ii|j 
impressed .iir, 2 \ 

etfe. Is 111, 2.S2 

nil h.i. eversion of, 79 
uie of light, 14, 30 

ill iitilis medi.i chronica 

.iilhi si\ ,1, I ; I 
in SI Toil-, 1 .it.irrh, 139 
mciission, 24 
of br.iiii, 2(1) 
of l.di\ ruilh. 2 |, 24I) 
inst.mt current. 2ss 
nistil' ition. 135 
uiscioiistiess, loss of, 40 
mtiiiiious-tone series. 50 
mtr.ieii n of external meatus, 174. 
rod 



IXDEX 



279 



Corrosive sublimati', Z2\ 
Cotton-wo<jl mops, 13 v 
Crcoliii, 151 . 

Croupous inn.uuin.itiou nt cMoru.ii 

lur.itus, 06 
Cur.'tt.ii;!' HI tuliiri iilar disiMSf, i.:;. 

12') 

Cun-ttc. i>olvpi. Id- 
Cysts, dcriuoiJ. ^7 

serous, of iiurirle, 88 

Dalbv, Sir Willi.iiu, ou f.i.i.il palsv, 

175 

Deafness, ^7 

Hiid life assurance, 2()7 
fune.tional, 251 
hysterical, 251 
o<;cupation, 246 
sliooter's, 246 
ncaf-iuutisni, 20 

aeipiired, tests, 26? 
Defonuitv, parattui wax for. 212 

plastic, operation for, 7'i 
Del.ived he.irink'. 43 
Uelstanelii\ extractcur. ,?oo 
luassafje, 75 
r,iref.ii-teur, 72, i47 
Dental burr. ■)'», 201 

chisel, 'I') i 

c.irie'- otalgia in, i^i 
Dermoid cysts, »7 
Dialietes, 44 
Din.istric, groove, !<), 211 

muscle, ig 
Dil.it.ition bv tents, lamui,i,-i,i. 17'"^ 
Dilators for collapse of meatus, loi 
Diphtheria. 113- ~^^- -•'- 
Diphtheritic intlanuuatiou of external 

me.uus, (j6 ^ 

Diplaciisis, 44 I 

Disch.irK'c, cessation of, i,s2 

chronic, acute exacerbations of, 

203 
char.ictiTs of, 3S 
diseases accomp.uued bv. 3S 
intiTiiiittent, 132 j 

.iltrusive, 152 i 

Dise.ises of external ear, 85 

of inlerii.'.l ear, 245 
Division of anterior lis.uueiil of 
malleus, 1118 
of posterior fold of membrane. I' /7 
of st.ipedius tendon, I't'^ 
of tensor tymp.mi tendon, 197 
I")omestic Servants .Act, 269 
Double hearing, 131 
]■ uclic, nasal, 7! 
D:. ight. f.icial palsv ,ifter. 121 
Dressiiit^s after m.istoid opi iMti'.in, 
210, 212 
after radical mastoid oper,,tion, 
2^0 



DressinRs after skin-sraftin«. 2211 
Drug's, (Effusion mto labyrmth from, 
42 

svm'>toms caused by, 42 
Drum, I ; 

artiiicial, 77- I'^o 

incision of the. i<)6 
Dry lips, 33 
Duration of disease, 26 
Dvspepsi.i, 135 

ll.iiulcnt. 2=;5 
Dystropiiy of liie neurones, 96 

ICar, .anatomy of, i 
discharge from, 38 
eczema of, acute, 37 
external, m.dformation of, 79 
intern, il, 7 

dise.lSeS of, 2 pS. 2 (7 

malign, lilt dise.isc cif, 230 
miilille, 4 
noises in, 41 
trumpets, 77 
s\ringing, 70 
Ears, artificial, 7<) 
injuries to. 82 
protruding. 80 
E.ist Co.ist. rest treatment, 245 
Eczein.i. acute, 37, 87. i|0 
extern, d me.itus, 21, 38 
imp<'tiginous, ui 
iMehuaim's pipes, 50 
i:dnc,ition. IM 
Effusion into l.ibyrinlh c.uiscd bv 

drugs. 42 
ICighth iier\-e nucleus, 255 

p,iir of ner\es. 7 
I^leclric burr, 216 

treatment, 238 
Electrolysis in chronic luistacluan 

obstruction, 112 
Emi'lovcrs' I.i.ibility Acts. 209 
I'^ii'io-lvmi'h. 7 
i:ndo-lymph.itie, sac, 8 
Cpilepsv. .inr.il. 253 
lipitheli.U plugs. lor 
Epitheliomata. 105 
Erosion of tin: internal c.irolid aiiery, 

171') 

)o 

ul .icutincss of lieariuR, 



Ilrysipcl.is. 
l''stuu,ae'ii 

47 
i:ther. 170 

so.ip. 22r, 
Ethyl chloride. 146 

iodide, 146 
Encaine, t8o 

i:ust.iclii.m bougie, iii. i p^ 
catheter. (>() 

1'. ihtzcr's metliotl. 07 
sterili/.ing, I19 
I inll.Uion m otoschrosis. 24 



1 


f 


mr 


r 


i 


111:/ 

it -i 


1 


1 


!'■■ 


I; 


-i 





IP!: ^. 






II! 



■'Hi 
Si- 



2S. 



IfASDliOOK Oh- DISEASES OF THE EAR 



III) 



Hustarhian mix. it,, ■^^ 

"li--tnii tinii. ai-.ut 
1 hroiiir, III 
Ulceration, liharvM,i,val .lul of, vS 
svi'hilitlr, iij 
tubi-ri iilar. 112 
Hiitlianasia, 237 
HxariTbatioiis', a. utp. in dinmir (lis- 

diarfji', 203 
Kxaiuiiiatinn nf patient, 2f> 
iif niastiiid ]>ri>c('ss, 27 
'if nasD-iiharynx, 31 
of nnsp, ■(I 
Kxantlii-niata, ^,1. 252, 2(>2 
Kxcisiiin of ossii Ics,^.)^ 

of thi' tympanic mcnitiranc, 244 
I-.xii|osions, 23 
I'.xtcrn.il au(litor\- meatus, i 
car, (iiscasi's of, .Sj 

lliT|><s of. ()4 
lupus of. 2«),S 

malformations of, 79 
new growths of, ,S,s 
sariduiata of. s,, 
meatus, al)s<'ess of, .,, 
bonv growths ..i, <)y 
cerumen in, 3, 102 
rolla|ise of mouth of, 1)2 
coutr.aeti.in of, 174. 201, 

croupous iii(lammatioti of, .jO 
diamoter of, 2 
diphtheria of, ,/) 
ec/cina of, 3S 
el'ithelial piuys in, -oi 
exostoses of, ,,,s 
foreipi 1)( idles in, 106 
furuneul.)sis of, t,^ 



10 



intlamination (jf, 
insects in. 107 
isthmus of, 2 
stenosis of, 100 
ulceration of, ()(, 
Extracteur, Delstan. he, 201 
l--.xtraction of sta|i(>s, 244 
I'^xtr.ulural abscess, i,Si 
l-.\ostoses, 98 



Facial asjiect. adenoids, 24 
iier\-e. s, IS 

•livided, treatment, 222 
m m.isf.jd o|ierations. 2()() 
m radical mastoid oin-ra- 
tions. 221 
palsv, 25, 42. 121. 17,, 
tciuporarx-. i,Si 
iMllopi.m canal, i.' 
I-'.iradic current. 121 
I'aliKue peruKl. (11 
I-'enestr.i ovalis, b, g 

rotunda, (> 
Ferri iierchluride, luiLture 11,7 
librolysis, 144 



-1)1, 205 



I'"iI)romata of lobule, ,S8 
1-ield's drums. 77 
Fissure, (il.iseri.ui, 8. 11 
l-'issures .if .S.mtorini, i 
Fistul.e, external, 174 

internal. 174 
F'ixation of tli<' uialleii 
Fo( us of h( ad-mirror. 
Forceps, H.irtmann's, 

Krause's. i 2 

Foreign bodies in e\t(rn,il meatus, 106 
rormalin, i2f), 172, 232 
Fossa of Kosenniiilier^ iS 

triauKularis. .s.( 
F'racture of liase of skull. 
Fri<'dreich on labvrinthme 
Frost-bites. .S2 
Fjiiictional deafness, 2=;i 
Furuniulosis, external meatus, 37, 
.VI. 94 

calcium chloride in, i/i 

perichondritis after, N.s 



^, 14S 
26 

201) 



- !• V) 
• eiiubion, 42 



1)1 



<iallou-i:dehuann whistle, so. 
(■altou whistle, 50, 141, 247 
(ialvanic (iirrent. 17s 
(■alvano-cautir\-, use .,f. ji, 
(■asseri.m ),',int;liou. injections of 

al( ohol. 241 
(lelle's test, sli, S^. 142 
lalivTinth. 241 
Gener.tl therapeutics. (15 
(jiddincss. transient. 40 
Gland, huiiili.itic. ii() 

sterno-mastoid, 122 
Glands, ceruminous. diseases of, 102 
Glaseri.ui fissure, N. 1 1 
Glue, for remo\al of f. 

Glycosuria, 44 
GoUf,'e. luttiuf;. 21.S 

(mastoid), 206 
Goiil.ird water. .S7 
(".out, 21, 135, 248, 250, . 
Goutv dermatitis, acute. i)o 
(ir.mular j'li,ir\nf,'itis. id, 142 
(.r.mul.uioii tissue, i6t 
(.r.mnl.itions, excessnc, 221. 22S 
Gr.i\'s aniline oil solution, 75, ud, 147 

I. So 
("■roove, dig.istric, 211 
Growths, bonv. i)y 

ivory, (jcj 

new, 1. 14 

spongs, .,<) 
Griibcr's ilrums, 77 

modilu .iiioii ot I'olit/eriuf,'. 00 

si'cc ulum, 27 
Gun-hrinp, dcidenirs for, 7S 
Guve, aprosexia of, 24 



oreign bodies, 



2.52 




o6 



42 



of 



IMJLX 



281 



Haninrrh ,!(;(' from the jugular bulb 
I7fi 

into tlif labyrinth, 256 

Icuk.iiiiic, 236 
H.iiiiatoia.i .iiiris. ■> ? 
Il.iuuurr ,uui chisel (ui.istoiil), 206 
H.irtui.iuu's attii- cuuiuKi. 12^, 162 

f<ir(',c|is, 200 

l>rnl>r, 172 
Hawkslfv's c.lav. 7S 
Hayncs's opcratiuii. 184 
Hearing, aids to, 77 

(Irlavcd, 45 

(loulllr. 151 

uuil.itcr.il loss of, ui chililrcu, 266 

wciknrss of, 2'n 
treatiui'iit, 262 
Hcbr.i's (liachvlon ointuicut, SH 
Heiile. spiui' of, 3, 209, 211. 216 
Heredity. 134 
Herpes, 85 

of external e.ir. 'it 
Hit;li-fre(]\ienrA ( urrent, 258 
History of jiatient, 20 
Hook, incus, 200 

str.iliisinus. 217 
Hornv «ro-.vth of .luricle, Sc) 
Horsley's rereliral iius-scarrher, 1811 
Human voice, testing witli, 48 
Hutchinson's tcitli, 21 
Hydr.irj,'. r. creta, 123, 204 

perchlor. li.]., 247 
Hvdrohroinic .icid, 144, 257, 258 
Hydrochloric acid, 174 
Hydro),'en I'croxide. iiS, ido. 172. iqij 
Hyoscvaniin. 240 
Hyper.icousis nervosa, 248 
Hvperacoustica of bone-conduction, 

248 
Hyperacusis, 4 t 

Hyjieni'sthesia .icoustic.i, 13(1, 183 
Hyperostosis, 07 
Hypoglossal nerve, 222 
Hysterical deafness, 251 
Hysteria, zz 

Ice-bat^s. 1S4 
InipetiKinous ec/.enn, 'U 
Incision, Bivokl's mastoiditis, 211 

lali\Tintli operations, izi) 

ni.istoid oper.itions, zo') 

of the ilriiiu, i')() 

radical ni.istoid. 215 
Increase of labyruithine pri'ssure. 252 

of intr.idabvrinthme pressure, 257 
Incus, 7, 9 

hook. 200 
Indicitions for intr.ui.isal treatnientt 

41 
for oper.ition in chronic suppu- 
rative disease. 204 
Infantile otorra.e.i. 150 



Inf.ircts, 2'\fi 

Infection, pathways of, 182 

Inferior turl)iiiate, 32 

enl.irfjement of, 36 

of posterior ends, 45 
Inllation. tympanic. 144 
Inliuen/.a. 22, 24'^, 262 

otitis after, 130 
Injec-tions (1--.C.) in otosiderosis, 242 

through citheter, 145 
Injuries, 2^ 

to auditory nerve, 246 
to ear. 82 

to internal e.ir, 246 
Insanity, h.rmatoma .uiris in, 83 
Insect in extern.il me.itus, 107 
Instruments, choice of, 206 

use of, 65 
Iiitenial carotid ,irtery, erosion of, 176 
ear, 7 

deafness, 247 
diseases of, 245, 247 
infarcts. 2,'i() 
injuries to. 24C) 
new tjrowths of. 2O3 
syphilis of, 24V 
juf,'ul.ir vi'in, 3 
Interstitial keratitis, 21 
I(xline, 145 

o'5 per cent., 242 
tincture of, 146 
Iodoform, 108, 118. 120, iCo. I7y, 1S5 
emulsion, 210 
Sjauze, 223 
in syphilis. 250 
Intracranial complications, 182 
di.ifniosis. 11)5 
intlnv.ivs of infection, 1^2 
Intradur.d .ibscess. ii|() 
Intralabyrinthine fluids, absence of, 

diminution of. 237 
pressure, increase of, 257 

Iron. 144 

iixlide, 2 (3 
t.irtr.Ue. 241 

Isol.itcd abscess in the mastoid, 123 

Isthiuiis of the Eustachian tube, 17 

Iter ad antrum, 15 

Ivory growths, o') 

Izal oil, 103 

in parolein. no 

Jugular Imlb. h.emorrhag'j from, 176 
vein, internal, 5 

Keloids of lobule, 88 
Keratosis obtur.ins, loi 
Knife, spud-shaped, 180 
Konig's rods, 47 
Krause's force]);;, 162 

osteotome, 201 
Kusier's mastoid op' r.uion. 227 




.i!?.. 



282 



I!AXD1J0(^!\ OF DISi:ASnS OF TIIF FAU 



178 



L;iliyriiitli, 7 

ciiiuussion of, J4, 24') 

(■riusic)i\ in, 41 

h,iiui)rrlKit;c into, 256 

niiTr.iscd pri'ssurr in, 43 

inll.imiu.iticiu of, ;5'» 

tircrosis of, 173 

oprr.iliiiiis on, 221), 232 
I.,ili\rinthci tomv, tot, J, 234 
L.iliynntluuc c '.psiili', m (rosis of, 259 

lllSlMSC, 11)1 

tuiiiuji-fork tests, 241 
prrssun', incri'usi! of, 252 
L.ilivrintliitis. ai.uto, 125 

supiMir.Uivi', 246 
L.K tic .uid. 12S 
l„uiiiii.iri,i tents, dihit.ition Iiy 
I..irvni:r,d mirror, 33 
L.itir.il nyst.iHnius, i6j 
jiliiirvuKitis, 142 

sinus, in lu.istoid operations, 223 
py.eniia, 192 
thronitiosis of, 192 

treatment of, Ij4 
Le.id, 262 
1.1 irhts, It7 

artitiei.il, iiS 
Letter-sounds, testing' v.ducs nf, 41) 
Leiuoeyth,enii,i, 24H 
Leueocytosis, 195 
Life assurance and 1 
Ligament, anterior, 
annul. ir, 10 
suspinsory. 9 
Ligation of common 
Liglita, liright, vertig. 
Linniient, A.H.C., 229 
Lip-readmg in deaf-mutism, zf'i 
Listerine, 12N, 132 
Lister's strong tiuu!, 129, 1S5, 201, 

210, 2I<) 
Litliia, c.„- -tL , I 44 
Lobule, abscess of, 07 
cysts of, dermoid, S9 

sebaceous, 89 
fibromata of, ^8 
Lucae's pressure probe, 147 
probe, 74 
tunmg-fork, 52 
Lumbar inmc.ture, 1S3, 195 
Lupus of external e.u", 208 
Lysol, iih, i.'iQ 

^h^^lline•glms, 246 
M,il,iria, 22, 24S, 251 
and quinine 2*12 
Malan.il poisonmg, 135 
Malfonuati'Mis .if exti rn.il ear, 79 
^Lllignaut dise.ise ot the ear, 104. 2j(i 
discliarge in, 39 
otalgia in, 38 
warts. 230 



ar disease, 267 

9 



cirotid, 176 
jc.iused by. 257 



>Ldingering, 2r)e 
Malli-ns, 7. « 

division of anterior ligaimnt of, 

1.(8 
fixation of tbe. 148 

tre.itment, 149 
m(;biliz;ition of. 149 
M.ilt. preiiarations of, i(>i 
Marage's svrtns, 47, 63 
Massage, .lir, 75 
piieumO", 75 
-Mastoid abscess, 22. 123 
antnun, 3, 15 

simple opening nf, .08 
examination of, 27 
gouge, 20S 

oper.ition. dressings .ifter. 210 
Kuster's, 227 
I>erichoiulritis .ifter, 85 
r.uiieal, 98, 213 

after-results, i2>^ 
.ilciihol in, 224 
liridge, tile. 217 
dressings after, 220 
j excessive granulations 

after, 22« 
I facial ner\e in, 221 

incision, 215 
life assurance, effect 0:1. 

2b& 
preliminary prepara- 
tions, 214 
teiniioral muscle in. 215 
V ■ !fe shield for, 221 
Schw. ' 208 

pain in, 24. ■ 
l)ersistent I'ain in, 2- 
process, 18 

operations on the, - 
seiui-r.idieal operation, 227 
Mastoiditis. 123 

Bezold's. 123, 204 

o|ier.ition in. 21 1 
non-tuliercul,ir. 202 
liost-inlluenz.d, 204 
tubercul.ir, 127 
vaccine ther.ipy in, 125 
Mandl's solution, 250 

WC.lk, 112 

Maxilla, inferior, 25 
MiMsles, 20, 113 

Meatus, external auditory, i; d. Kxter- 
ual auditory meatus 
contraction of. 174, 206 
di.imeter of, 2 
ec/ema of. 3S 
' furunculosis of. 37. 39 

isthmus of. 2 
.Membr.tii.i ll.iccida. 13, 153 
j luopri.i, 12, 153 

I tyiiipani. 12 

• u tun i.d. li'i 



of, 



ions 



0:1, 
ar.i- 



■215 
Z21 



i\Di:x 



JS3 



tor- 
itus 
zo(> 



3'> 



Meiubruiia tyiupani, calciruous 
(h.uiKi's in, i;i) 
division of posterior fold of, 

i')7 
examination of, 29 
in .idenoids. 43 
jierforation "f. i=i- 
piisl-supiiurative changes in, 

pulsation uf. 177 
qn.idr.ints of, 14 
rupture of, 23, loS, 269 
stretcliint; of, 148 
structure (jf, 12 
Mcinbranoiis lal)yrintli. 7 
Mciuorv, loss of, 1S7 
Meni. re's disc--, 41, i|2. 2ti- -;<J 
Meningitis. iK.:. 232. 2114 

Haynes's operation, 184 
treatment, 183 
vaccine treatment, liSj 
Menthol, 145 

Mercury, bmiodide, loS, i^'i. 243 
oxidi' of, ointment, 11 1 
perchloride, 118. Ij9, 172 
(f. hvdr.irg.), 183 
yellow o.xide cif, 104 
Michel's mirror, 33 
Middle ear, 4 

acute diseases of, 113 

tubercular disease of, I2() 
chronic noii-suppurati\ e dis- 
eases of, 134 
suppuration of, 150 
serous catarrh of, 131 
tuberculous (liticase of, 203 
Military men ,uul sound-deadeners, 7b 
Minor operations, I'jo 
Mirror, he. id, 26 
Miclu'l's, ,]>, 
Mobihzalion of malleus, 149 

of stapes. 244 
MckUoIus, Zi^ 
Moi--.^,;:jrd. Stult/.'s, 47 
Mouth-breathiiiK, 25, 35 
Mops, cotton-wool, 154 
Miico-poriosteum, 4, 7 
Muiuiis, 248, 232. 202, 264 
Myringotome, i.So, 197, 200 
My.\o-sarcoina, 237 

Nasal disease, obstructive, 113 

douche, 7 i 

ill-effects of, 114 

irrigations, 40, 12.S 

speculum, 32 

sprav, detergent, 132 

trr.itmeiit, mdic.itions for, 44 
Naso-pliarvi.<, examination ot, 3 

muco>a of, 113 
Nausea, 43 
.\avai men ,ind souiui-iie.iciiuei >. /o 



Necrosis of lativrinth, 175 

of labyrinthine (-.ipsulc, 239 
of the ossicle>i, I 72 
of the temporal bone, 173 
Neur.algia. post-operative. 229 
Nciira^tlvuia. 22, 255 

of .iuditory nerve, 2i'l 
Xei.ritis of auditory nerve, 202 
Neuroma, 263 
New growtlis, 104 

ot e\t<Tnal ear, 8S 
of internal ear, 2(13 
Nerve, auditory, qv. 

great .i^;ru:uK.r, 2 14 
Night terrors, 25 
Nltro-p. iwders, 2 p> 
Noiso-priKl'icer of B.irany, 49. t'3 
Noises in the ear. 41 
ol)jecti\e, 42 
referred to head. 41 
referred to the ear, 41 
subjective , 41 
vertigo caused by, 257 
Non-aural vertigo. 258 
Norni.il saline solution. 119 
Nose, blowing of. T . t. 149 

examination ot. 31 
Nose-blowing, evil etlects of, 24') 
Notch of Ki villi, 13 
Nux vomica. 2*14 

Nystagmus, 43. I5^. ^^i- 1S4. i')o, 256 
in e.iloric test, 2O0 
lateral, 1113 

Obstruction, ICustai hi.m tube, no 
Dccipation, 2^ 

deafness. 2 pi 
Olfelisive disrliarge, 132 
tjpi-r.ition. lii/old's iii.istoiditis. 210 
cocliliM. .ilil.ilion lit, J33 
for tinnitus. 2ii 
Havnes's. 184 
indications for, 125 
in suppurative otitis. 19H 
Kuster's. 227 
ju lalivrmth, 229 
on nuistoid princess, 2'<2 
Schwartze's, 202, 208 
Operations, minor, 196 

plastic, 79 
Operative treatment of tinnitus, 2.; i 
Oliiuiu, 1S3, 24H 
Optic neuritis, iS.S 
papillitis, 191 
Ordnance, hring of, 24 
O (j-pliarynx, granules in, 35 
Ossicles, 7, H 

caries of, 156 
excision of, 244 
necrosis of, 172 
j ', )ssicul( ctoniy, 102, 19S 

Obic' 'potoSiS, -50 



284 



iiAXDnooK or Disi:.isi:s or riir i:,iu 



Ostcotomi-, Knu.scs, joi 

Otalgia, 37 

alcohol injprtions in, 24 j 

from arthritis of ti iU|ioro-iua\Ll- 

larv arti( Illation, js 
in (h-iital rarics. j.s 
in mti'rn.il car disease, ^S 
in malifjiiant disease. 3H 

(Ith.cniatoiaata. j,i, .Si; 

Otitic, eenlira! abscess. i86 

Otitis externa, ')0 
interna. 250 

treatment, zfn 
media aciit.i. 1 13 

COmpllC.ltinnS nf. I.M 

l)atholo('y. 1 1.| 
svmptonis. 114 
treatment. 117 
vertigo in. 125 
clironi( .1. ,idlieM\,i \,1 |i\-. 

I'ertroiiliic a. i ) 
lueniorrliaKica. ;.). I V> 

a( nta, i {o 
siiii|iiir,ifiv,i, 22 

and lite assurance, 268 
acuta, v) 
chronica, y), 150 
roiuplications. 163 
nieniPK; j in. i>S2 
Oto-iuassaKc. 148, 24J 
Oto.m.isseur. yt> 
Otomv( osis. 31). 1)2 
Otosclerosis. 142. 2?K, 241 

ixirt.ible telephones for, 78 
0\er-e\crti(in ,iinl \. rtiKo. 258 



P 

r 

!• 

p. 



.nil 1 1 the 1 .ir. 57 
'al.ite, .ircliinn ot. 24 
alsv. Hells, 175 

tai ial. 121 
.ipaine, 172 
.i|iilluis. i.ss 
a|>illoni,it.i. lo) 
ar.icritc ^is, njd 
.11.11 n^is lo( i. 1(7 

\\ illisii. 137. 241, 241. 
ir.iKiii w.ix mjeciions. 212 
.iralysis in c.rchr.il .ihs' i-ss. i8S 

f.ic-i.il. 42. 175 

of sixth nerve. 43 
:iro|ene. sterili/.ecl. 22(1 
itluv.iys o' mhctioii. i.Sj 

client's .ispect. 2 I 

history. 20 
present historv, 2(> 
st.ile. 24 

spiTialex.iminationof, 26 
•pper. 14 ( 

rceptioii, slnnKisli. 44 
ri hloruli-, nierciirv, ii!i, ijij, 17^ 
rtor.itioii ot memhrana tvinp.uii.'ija 
rluratioii test, 2'n 



, Perichondritis, .iciite. of external ear 

rcri-hin|>h. 7 

I'enphir.il opacit>', circular, 31 

'\roxide hvdroL'en. 199 

I'etroh'iim molle, 145 

I'ctrous hone. .s. i~ 

I'l. lit.:. I II ' 

l'h.ii\ iiL;itN. granular, j'., 142 

Liter. il, I ( .; 
I PhosphorMs. 2 I \ 
Photci(iholii,i. i.S) 
Pli\>ioio^,c,il re-t. 245 
I'lloc.irpin. 2p). 253. 25S, 262 
I'iniia. I 

I'l.lstli; oper.ltion;-, 7,) 
Plugs, epithelial. loi 

of sterilized \v ix. 17*) 
PneiiTiuitic. speculum, 71 
I'luiiiuo-massage, 75. 148 

m otosclerosis. 24 ) 
I'lieiiiuonia. 2^2 
Pollt/.er's .icolliueter. 51. 247 

l>ag. 65 

for removal of foreign 
liiKlies, 107 

til .itiiirnt of polypi, 168 
PGlit/cri/ation. i-s, 144 

( in iber's III' Kfilic.it ion, 00 
I'olvpi. .uir.il. i(i.|, 107 

I hroiiiic .icid, i()7 

curette, I()7 

formation of. i !(> 
Polit/er's treatment, 108 
Ml. ire. i(>o 
I'' ii tabic telephones, 78 
I I'ost-.iuriciil.ir clitt. 27 
I'ost-n.is.il I .it.irrli, 30 

mirror, 3,s 
Post.o,ii r.itive neuralgia, 229 
Posterior rhinoscopv, 3; 

'01 .line 111. i4 
Pot.lSSlUIU iodide. 14^. 243, i;, Ml), 

-'58 
Pravaz svriiif.;c. i (^ 
Prescriptions (sec Appendix also) : 
.diohiil. IIM, 

bi U.idi.nn.i .iiul j^hiciinr, i.:3 
( .ill mill s.ilt .. 130 
lorm.ihn. i2i| 
(iray's coi ,uiie S'liutiiui. 73, ijii, 

147. !**<> 

Hebr.i's di.iib\ loll oiiitiiicnl. s.-i 
hyd. c. crct.. 12 \ 
pin Idol.. 07 
hydrogen piToxide, lOo 
hyoscy.imin, 24<) 
iiKlme 111 sp. chloroform, H6 
l.ictic ,i( id, 1)7, 12!^ 
Lister's strong so|iiii..ii. 121). 185, 
201. 210, 210 

l.lsli nile. 1 jS, [ jj 



i.\i>i:.\' 



a85 



c^r, 



:i'J. 



8rt 



«5. 



I I 



Pr('sr.riptions : 

litliiit. I I ( 

i>ili>( .irinn. .'40 

potiiss. ii«l., tj.v. 

saliiylic. .iciil, in I 

sikI. bif.irli.. i \s 

strvrhni.i, 14 i 

thymol in alcohcil, 86 

uni,'. hyclrartj;., .S() 

liyd. aiumon. dil.. 102 

v.ili'n.m. 144. 2\n. J IV. 231. ;.=iS 

zinc oli-.iti', ,N7 
Prinuirv mw Hruwth^ of uUr; 11, il r.ir, 

I'rolir. ll.irtni.iiiu s. i 72 

l.U(,ii-'s, ri. 

xulcaniti'. 11) ( 

WiK.xlrn. 1114 
Pro(<'Ssus lircvis. '^. 14 

KI-.IC ills, () 

Proniontorv, 6, S 

trciihinin;,' of. 2) ^ 
Prophvl.ixis, adenoids, 45 
Proportional test. 5S 
Protrui'.iny cars, Ho 
" Proud tic sh," 165 
Pscudo-Miiiiirc, z(t2 
Pulsation in exudation. 137 

"f luciuliraiia tviiip.ini, 177 
I'lijiils. dilat.ition of. tS} 

in ccrrlir.il .ibsccss. i'<S 
Pv.i lUM. lateral sinus. 1<)Z 

Kailieal niast'iul 'i\i' ration. 21 1, 
Ran l,i( t:'ur. ' lelst.nielic. 72, 147 
l\e-edllc.ltloll. (1 5 
Kela.xed thro, its. 20 
Rest. ph\siol.ii,'icMl. J !■-, 
Kctro-auriiul.ir dcrinoid cyst, 88 
Klieuiu.itisin, 21, 24S 
Kliinilis. .ilrophii;, 33, 46 

hvpei trophic, 40 ' 

sii ( a, ^^. 2A2 

Khinosi-opy, p<isterior. 31 
Kii^'irs, 43 

111 ceiebral abscess, 1.S7 

Killllrs list. 3.'^, 141, 247 

double ne«.itive. 78 

l.iii\ruith, 241 
Riveters. 2 \. J |() 
Kuiiii. iioli h of. I 5 
RcKlent ulcer. 2 ill 
Koni iiinuller. foss.i of. is 

uher.ition of. 112 

Kot.ltorv tests. 2l'i) 

Kublier sound-d<Mdener, 2(3 
Rupture lit uuiulirana tyiup.mi. los 

Salii;ine, 262 
S.Uicvl.iles, 21. 2 C^ 

svinptonis cuni d bv. (2 
S.dii \lii .11 id. i~2 



S.dvars.in, 230 

Santnrini, einissnrv vein of, if)-' 

tissur"s of. I 
S.irconi.i. ii)(). 236 

of external ear. S') 
Scarlet fever. 20, 113. 2(14 

toxic, 262 
Scheme for recording tests, 78 
Sch\vartze"s operation, 202, 208 
Secretion of 1 eruiiii n, exces-ive, 10 
Seinifiircular canals. 7, .s. 40 

erosion of. 40 

extern. d, I'l 5 
Seini-r.idu .il in.istoid operation. 227 
Sep lis, chronic, mi 
Si'quela'. chronic sU|ipur.ilion. uiiddh! 

ear. 177 
Sequestrum in tuben ul.ir ilis.M^e. 129 
Serous e.itarrh of ilie m:ildle e.ir. i ;i 
Shock, foil, iwint; use of h.imiin r. 200 

incre.ise of. 20I) 
Shooter's w.ix, 245 
Shr.ipneli's membr.uie. i i. i ). 131 
Si(rl<:'s speculum. (1.71 
Silver, nitrate of. i p* 
Simple opeiutih' of the m.istoid 

antiuin. 208 
Sinus in pl.ice of prrtor.aimi. 15 \ 
Skin Kraftint;. 223 

incision, t'. Incisions 
Skull, fr.icture b.ise. 3«) 
Snare, (iriiber '», i()7 
Snorint;. 2 t 
Snullles. 2J 

Scxlium hic.irbonate, 145 
Softeninw w.ix of e.ir. 103 
Sore throats. 20 
Sound de.idi'ni-r. rubber. 243 
Spi cl.d tests, 37 
Spei Ilium. I'lriiber's. 27 
piieniu.iti . 71 

Sleule's. 71 

'rhudicum's. 32 
Spine of Henle. 5. 21)11. 211. 216 

postirior lue.it.d. t 

superior ine.it.il. i. 21I) 
Sponi;v pedunciil.iti- 1 iirouth... i)<) 
Sportin»; men .md sound dt .idciiers, 7>i 
Squamous lx>iu-, 15 
Squ.uiioiis-rclled carcinoma. 236 
Squamo-pelros.il suturi . > 
Squint, 183, ii;i 
Stapes, 6, 7. I) 

ankvlisis of. 2 1 1 

citcunii'isioii ol. i.Ho 

extr.e lion of. 244 

mobiluation of. 2 n 
Stapedius muscle. 5, 10 
tic of, 42 

tendon, division of, l<>S 
Staf^hyliiciiccus alhtis. <M 

(iiireii>. IJ4 



286 



Il.lXDfJOOK OF DISF-:.lSi:S OF THE EAR 



Stoiiitsis of I'xtiTual niuatiis, lou 
Stcrno-iuastDid f^land, i2z 
Strabisiuus bo^^k, 217 
Strutchiug Uic tviiiiMiiic nu labiauc, 

Strychnia, 243. -47. 25t>. 231 

in otitis media chronica adliesiva, 

Stiilt/.'s nioaocliord, 47 
Sulcus tympauicvis, 12 
SupiTiunucrary auricles, ;<) 
Suppiuative disease ot luuldl.' car 
and life assur- 
ance, 267 
wlien dirauic?, 130 
Susprnsory ligament. >) 
Suture, s<iuamo-iietrosaI, 4 
S\philis. 21, 24.S 
ai.(|uire(l, 241^ 
i\ternal meatus, 96 
heredit.iry, 23S, 249 
internal e.ir, 249 
Syrens, Marage's, 65 
Syringe, I'ravaz, 141 
Syringing ear, 70 

giddiness alter. 40 
position m, 40 
tecluiicpu; of, 103 
\'ertigo after. i() i, 205 
Symptoms caused by drugs, 42 

Teginen tympani. 4 

Telephones, portalile, 7.S 

m :;■ leral tlicrapeuth s, 24'i 
Temporal boue, ui( rosis ol. 173 
supi>ui.iiion in. 37 
tubiTculai disease of, ij.) 
Tcniporo-maxillary artieul.ition. 3'< 
Temporosphenoidal lobe. iSo 
Tempeiature of water tor syringing 

ear, 103 
Tensor tympani, division (ji ti iidon 
ot, I. ,7 
Tuuscle, (), 7 
Tents, laminana, dilatation b\-, 178 
Tests, caloric, 200 

continuous tone series, 50 
di-.d-mutism, 203 
fatigue period, (>i 
• ■elles labvrmth, 2 \\ 

llUlll.in Voire, 41) 

perforatioti. 2(11 
liro[)ortioji.il. 5H 
Kinne's, J^ 
rotatory, 200 
srlieim; for recording, 7S 
spei:ial, 57 
tuning-fork, .ss, 2 1 1 

.uiom.dous n sulti m, (12 
.uigles, I12 
\V( bi-r's, S/ 
Tber.ii'eulUKi, general, 05 



Therapeutics, general, of intemal-rar 

dise.ises, 243 
Thiersch's graft, ijo. 224 

knife, 225 
Thiosinamiiie. 144 
Thread, tor r.'uiov .il of foreign bixlies, 

107 
Ihrombosis ot lateral '-■ins, 192 
Thudichum's speculuin 2 
Tinnitus. 41. 157 

and life .issurance, 2(17 

examination of urine in, 42 

in concussion of lab\rinth, 2(6 

objective, 42 

openuive treatment of, 231, 2(4 

radical mastoid (jperatiou tor, 
244 

snicidi- from, 42 

treatment. 140, 254 
Tobacco, 24'*, 202 

excess, 23 
Tongue depressor, 33 
'Tonsils, faucial, 36 

n.iso - pharyiige.d, hypertrophic 
disease of, 113 
Toynbee drums. 77 

on adenoids, 31 
'Tre.itment. .icute lUNt.i' lii.m ob- 
struction. iii> 

alcohol iiijei:tions, 244 

aural poly|ii, idi) 

cerebellar abscess, kji 

cerebral abscess, it>() 

cerumen, 103 

cholesteatoma, 170 

chronic iiust.ichian obstruction. 
112 
suppur.ition, i.vS 

concussion of labyrinth, 247 

divKled facial ner\e, zzz 

ele( trolytic, 112 

erosion of internal carotid, 17(1 

extr.idural abscess, i«.s 

taraihr < iirreut, 121 

h\atioii of the malleus, I4'> 

galvanism. 175 

hvpcr.icousis nervos.i, 24<) 

iiicre.ised labvrinthine pressure, 
253 

insc( t in nie.iius, io,S 

intradural absc( Ss, i.|i> 

lati r.d sums thrombosis, i^ji 

m.istoiditls, 124 

menini;itis, iHj 

neuritis, .ludilorv ner\i'. if^\ 

otitis interna, 2O1 

media clironii ,1 .idln siva, 
143 
.iciit.i. 1 17 

otoinvcosis. 1)3 

otosi lerosls. 2 |2 

pertor.itions, 17,, 



rXDFiX 



287 



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iir<>, 



Treatment, post-nprrativo nriir.ilf,'ia, 

rest, 245 

rupture luembrana tvmiiani, loh 
serous catarrh of raiddlt; ear, 13 J 
tinnitus, 146, 254 j 

operative, 244 
tubercular disease, 127 
tvuip.iuic attic, 162 
vaccine therapy, 125 
vapours. 140 
%veaknessof hearing. 262 
Trephuiiufj; of thi- prouiontory, 21-, 
Triclilor.ici^tic acid, 16;, 179 
Tropics, residence in, 22 
Tuberculous disease of middle ear, 
126, 203 
of tempor,d bone, 129 
treatment, 127 
Tuning-forks, ^o, 247 

anomalous results, Oz 
Lucai's. 52 
test, 2 SI 

labvrinth. 241 
Tunmlling (le.cupations, 23 
Turbinate, infi-ior, 2O2 
Tympanic attic, chronic supiiuratimi 
of, 161 
cavitv, 4 
membrane, 4, 11 

artilK-i.il, 77, iHo 
excision of, 244 
Tvphoid, 2t'<, 2^2. 262 

ricer.ition of external meatus, qO 

I'inbo, II 

Und.iteral loss ot licirnm in diiliiren, 

2M> 

I'nhvgienic surruundinps. 22 
I'rlcuitsctiitsch. aioustlc exenises, 

2(.( 

harmonium of. hi, 
Vrine. eN.unination of, 20 

V.ieeine tlirrapv. 12S 

menini^itis, i"i3 
V.ilenan. 144, 240. 2(0. 2.S1. 2^S 
V.ilsalv.i, experiment ol. i \X, 111. > 1^ 
N'.ip.iurs, I pi 

ben/i'in III 
\'em. Miti rnal |iit;iil.ir, S 



Vertigo, i 35. 142. 253 

and lifi- assuraiK'.e, 267 

and o\..rstrain, 25S 

apoplectiform, 258 

aural, 3<) 

cnises, 254 

caused bv brii;ht lights. 257 
by noise, 257 

due to h.rniorrhage ii\t 1 laby- 
ruith, 25') 
to (biiunution of fluid, intra- 

labvrnithine, 257 
to diminution of .irtirial 
lin-.ion, 258 

dyspeptic, 25 S 

from |>olvpi, 164 

general, 40 

gout v. 2, 5 8 

in 'jtitis media acuta, 125 

in fr.icturc b.ise, 247 

in svruiguig ear 

later.il. 205 

non-.iural, 258 

of central origin, 

S)>ecitic, 40 
N'estibule, 7 

.iqui-duct of tlie, 
\'estii)ulotomy, 250 
\'ocal sounds, testing v.ilues of, 4() 
Voice tests, 47 
Vomiting. 43 

in cerebell.ir .ibscess. Kjl 

in cerebr.d , ibscess, 1^7 
Vulcanite f.ms, 77 

shield for dressings. 221 

sound-deadeners. 78 

W.irts, malign. uit. 2 V 
W.itch, testing bv, 11 
Wax, 3 

in children, 102 

softeiung. 103 

stenll/ed, 210 
Weakness of he.iring. 2fii 
Web, cicitric.ial. Ui me.ltus, 177 
Wibs, acipurrd. 100 
Weber's test, "17. I4I, 248 

Wiri' loop f,ir foreign IhmIics, 107 
Whispering, .;■ 

WoU, ()., on Itstuig vali' s ot soiuids 
4<) 



103 

25^ 
8 

V.llUes of. 



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